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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425610
Report Date: 03/21/2025
Date Signed: 03/21/2025 04:47:53 PM

Substantiated


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
07/27/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230727155713
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: 4DATE:
03/21/2025
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Dorris AndersonTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are not ensuring that resident attends medical appointments.
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 Licensee, staff, resident, outside party interviews and pertinent document review.

Regarding the allegation, staff are not ensuring that resident attends medical appointments, the Licensees’ interview reveals, resident #1 (R1) missed their doctor’s appointment due to not having help to transfer resident out of bed. Facility staff were not able to transfer R1 out of bed to attend their doctor’s appointment due to R1 being too heavy. Although R1 had transportation available for doctor’s appointments through an outside agency, drivers are not permitted to assist facility staff with out-of-bed transfers. LPA review of resident appraisal of services needed reveals, R1 needs help in transferring in and out of bed or chair.

Based on evidence obtained during this investigation, the allegation is Substantiated. A substantiated finding means that the allegation(s) is valid because the preponderance of the evidence standard has been met.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
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-20230727155713
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: 03/21/2025
NARRATIVE
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An exit interview was conducted where reports (LIC9099&LIC9099-D) were discussed and provided with appeal rights to Licensee Anderson at the conclusion of the visit
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20230727155713
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: 03/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2025
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities(a)In addition to the rights listed in Section 87468.1...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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R1 no longer resides at the facility. The Licensee shall review the regulation cited and provide a statement of understanding to the Licensing agency by POC due date.
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The licensee did not comply with the section cited above by not ensuring R1 had adequate services and staff to meet their needs, which poses an immediate, health and safety risk to persons in care.
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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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
07/27/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230727155713

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: 4DATE:
03/21/2025
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Dorris AndersonTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
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Staff are not ensuring that resident has access to a phone in their room.
Staff are not ensuring that resident has access to a tv in their room.
Staff does not allow resident to interact with other residents.
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.

Regarding the allegation, staff are not ensuring that resident has access to a phone in their room, interviews with the Licensee, two (2) staff, five (5) residents reveal not enough witnesses to corroborate the allegation.

Regarding the allegation, staff are not ensuring that resident has access to a TV in their room, interviews with the Licensee, two (2) staff, five (5) residents reveal not enough witnesses to corroborate the allegation.

Regarding the allegation, staff does not allow resident to interact with other residents, interviews with the Licensee, two (2) staff, five (5) residents reveal not enough witnesses to corroborate the allegation.
**continued on next page***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230727155713
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: 03/21/2025
NARRATIVE
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Based on Licensee, staff and resident interviews, the allegations mentioned in this report are 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 where this report (LIC 9099) was discussed, and a copy with appeal rights was provided to Dorris Anderson at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5