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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 10/01/2025
Date Signed: 10/01/2025 02:39:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
09/23/2025 and conducted by Evaluator Edith Conchas
COMPLAINT CONTROL NUMBER: 56-AS-20250923125605
FACILITY NAME:ROSE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:SCHAMONE BARDFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:63CENSUS: 50DATE:
10/01/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Schamone BardTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Licensee does not ensure that staff follow proper infection control protocols.
INVESTIGATION FINDINGS:
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On 10/1/2025, Licensing Program Analysts (LPA) Edith Conchas and Sarina Ramirez conducted an unannounced visit to conduct an investigation on the allegations listed above. LPAs met with Facility Administrator Shamone Bard and explained the purpose of the visit.

First Allegation: Licensee does not ensure that staff follow proper infection control protocols.

During the investigation, LPAs Observed pertinent records, the current infection control plan was not updated and No In-service training for Infection control on Covid-19.

LPAs conducted Four (4) staff interviews and five (5) residents interviews. In addition LPA took a tour of the facility with the Administrator Shamone and were able to obtain sufficient evidence to corroborate the allegation. Two (2) out of four (4) staff stated the PPE procedures can be more strictly enforced due to witnessing other staff not following procedures.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
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 3
Control Number 56-AS-20250923125605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
VISIT DATE: 10/01/2025
NARRATIVE
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One (1) of the four (4) staff informed LPA the first days of residents testing positive there was not enough PPE supplies.

LPAs observed in three(3) storage areas there were individual boxes of gloves, boxes of gowns, N95 masks but no supply of surgical masks available. Administrator informed LPAs due to providing masks to resident's family, and no longer having positive covid-19 residents; the supply is now low.


Based on LPAs observations, record review and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 & Chapter 6, are being cited on the attached LIC 9099D
Therefore, the allegations that; Licensee does not ensure that staff follow proper infection control protocols was found to be SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted, and a copy of this report LIC9099,LIC9099C, LIC9099D was provided to the Licensee Shamone Bard.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250923125605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2025
Section Cited
CCR
87470(c)
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87470 Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.
This requirement is not met as evidenced by:
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Administrator will provide updated Infection control plan and procedure and will conduct in In-service training on Infection Control guidelines and procedures on communicable diseases by POC due date.
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Based on LPAs record review, observation and interviews Licesnee did not have an updated Infection control plan nor an infection control training completed on Covid -19 use of Personal Protective equiptment (PPE). This poses a potential risk to the health safety and personal rights of residents 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: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3