<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 10/30/2023
Date Signed: 12/15/2023 04:52:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2023 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20230912084226
FACILITY NAME:ROSE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:MORGAN E. WILLIAMSFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:63CENSUS: 56DATE:
10/30/2023
UNANNOUNCEDTIME BEGAN:
05:13 PM
MET WITH:Leilani Cortez-LVNTIME COMPLETED:
05:14 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained an unexplained bruise while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the allegations above. LPA Allen met with Leilani Cortez-LVN who was informed of the purpose of the visit.

The investigation consisted of interviews with staff members, outside parties, and review of Resident 1 (R1) medical records and facility file. The interviews with staff members stated they did not see R1 fall outside they only observed R1 laying on the ground and could not explain how the bruising/scars happened. There were no witnesses that could confirm if the resident fell resulting in unexplained bruising. LPA observed pictures and reviewed medical records that reflect there were bruises and scares on the face and wrist of R1 that could not be explained. LPA did attempt to interview R1on 9/18/2023, but they were at a doctor's appointment.

Based on LPA observations, documentation and interviews the above allegation is found to be Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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 3
Control Number 56-AS-20230912084226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
VISIT DATE: 10/30/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

A deficiency is being cited on the attached LIC 9099-D.

An exit interview was conducted where this report was discussed, and a copy was provided to Leilani Cortez-LVN at the conclusion of the visit with appeal rights.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230912084226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
CCR
87705(l)(5)
1
2
3
4
5
6
7
87705 Care of Persons with Dementia The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: available on the facility premises to permit residents with dementia to wander freely and safely.
1
2
3
4
5
6
7
The licensee has agreed to provide training to all staff and provide a written statement of understanding of the cited regulation signed by all staff member by the POC of 11/3/2023.
8
9
10
11
12
13
14
Interior and exterior space shall be... This requirement is not met as evidenced by: The staff did not esure the saftey of the resident while in care that resulted in unexplained brusing.

8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3