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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425610
Report Date: 09/08/2023
Date Signed: 09/08/2023 10:21:37 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230721153154
FACILITY NAME:EXCELCAREFACILITY NUMBER:
366425610
ADMINISTRATOR:ANDERSON, DORRISFACILITY TYPE:
740
ADDRESS:11400 POPLAR STREETTELEPHONE:
(909) 796-4553
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:10CENSUS: 8DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Dorris Anderson, LicenseeTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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9
Staff not rotating and repositioning resulting in resident sustaining a pressure injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Dorris Anderson, Licensee and discussed the purpose of the visit.
The investigation consisted of LPA observations, pertinent document review, and interviews with relevant parties.
Regarding allegation, staff not rotating and repositioning resulting in resident sustaining a pressure injury, Licensee and staff interviewed deny resident sustained a pressure wound do to staff not rotating and repositioning. Licensee stated that resident 1 (R1) receives bed baths and repositioned regularly to prevent pressure injuries. Interviews with medical professionals reveal that pressure injuries were not observed on R1.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 56-AS-20230721153154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EXCELCARE
FACILITY NUMBER: 366425610
VISIT DATE: 09/08/2023
NARRATIVE
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Based on information obtained during the investigation, the allegation is Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
An exit interview was conducted with where this report was discussed and a copy of this report with appeal rights was provided to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230721153154

FACILITY NAME:EXCELCAREFACILITY NUMBER:
366425610
ADMINISTRATOR:ANDERSON, DORRISFACILITY TYPE:
740
ADDRESS:11400 POPLAR STREETTELEPHONE:
(909) 796-4553
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:10CENSUS: 8DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Dorris Anderson, LicenseeTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
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5
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8
9
Staff withholding food from resident
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Dorris Anderson, Licensee and discussed the purpose of the visit.
The investigation consisted of LPA observations, pertinent document review, and interviews with relevant parties.
Regarding allegation, staff withholding food from resident, Licensee stated that the resident 1 (R1) is provided breakfast, lunch, and dinner; however, Licensee is limiting R1's snacks to one a day due to lose weight. Licensee stated that the resident is obese and is too heavy for her and staff to lift her safely. LPA review of R1’s physician’s report reveals R1 is not on a prescribed special or restricted diet.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20230721153154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EXCELCARE
FACILITY NUMBER: 366425610
VISIT DATE: 09/08/2023
NARRATIVE
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Interviews with pertinent parties reveal that R1 asked staff for more food and R1 was given a piece of bread.
Based on information obtained during the investigation, the allegation is Substantiated. A finding of substantiated means that the preponderance of the evidence standard has been met.
A deficiency was citied, and a plan of correction was discussed with the Licensee.

An exit interview was conducted and copies of reports LIC9099 and LIC9099-D with appeal rights where provide to the Licensee at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230721153154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EXCELCARE
FACILITY NUMBER: 366425610
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2023
Section Cited
CCR
87555(a)
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87555 General Food Service
(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents…
This requirement is not met by:
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License shall submit a statement of understanding on the cited regulation and understand that dietary limitations shall be prescribe by a physician.
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Licensee stated that resident is obese and is limiting in-between meal nourishment or snacks to resident
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5