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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 12/19/2025
Date Signed: 12/19/2025 02:44:52 PM

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
01/14/2025 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250114083545
FACILITY NAME:ROSE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:GARCIA, CELIAFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:63CENSUS: 55DATE:
12/19/2025
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Schamone BaredTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not ensure that resident's responsible party is notified of changes in condition.
Staff do not respond to calls from resident's representative in a timely manner.
Staff do not respond to resident's calls for assistance.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Schamone Bared and explained the purpose of the visit regarding the allegations listed above.

First allegation: Staff do not ensure that resident's responsible party is notified of changes in condition. Regarding the allegation stated above, LPA conducted an interview with S#1 LPA went over the alleged allegation with S#1 and S#1 informed LPA that the facility will inform R#1 responsible party/and or conservator regarding the changes or incidents involving R#. LPA collected all documentation along with special incident reports involving R#1 during review of records (Special incident reports) LPA discovered that the facility would notify R#1 responsible party of the incidents involving R#1. In addition, records also showed that the facility was also notifying the appropriate agencies regarding incidents involving R#1. LPA conducted interviews with Residents #2-4 LPA went over the alleged allegation with the residents and all informed LPA that they have no concerns regarding the facility not communicating incidents that involve residents change of condition to residents’ responsible party.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
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 2
Control Number 56-AS-20250114083545
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: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
VISIT DATE: 12/19/2025
NARRATIVE
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 In addition, during record review LPA observed that R#1 was admitted to Rose Gardens on 3/15/2024, during R#1 admission R#1 did not have a responsible party appointed. During further review, LPA observed that a conservator was appointed to R#1 on 10/6/2025.
Second allegation: Staff do not respond to calls from resident's representative in a timely manner. Regarding the allegation stated above, LPA conducted an interview with S#1 regarding the alleged allegation S#1 informed LPA that all calls involving R#1 were returned back to the responsible party. In addition, S#1 informed LPA that the facility encountered issues locating or reaching a responsible party for R#1 and the facility appointed R#1 to a public guardian/Conservator that would manage the financial and responsibility for R#1. LPA conducted interviews with R#2-4 LPA went over the allegation with the residents and all informed not having concerns regarding facility not returning or responding to calls. LPA conducted interviews with S#2-3 concerning the alleged allegation and all denied the allegation regarding staff not responding to calls from resident[s] representatives.

Third allegation: Staff do not respond to resident's calls for assistance. Regarding the allegation stated above, LPA conducted a walkthrough of the facility LPA observed a call system to be in place inside the Med-Tech office. LPA inspected the call system and observed that a few lights were down the Maintenance Director informed LPA that the facility had an annual inspection on 12/5/2025 and were issued a deficiency with a Plan of Correction. Maintenance director informed LPA that the facility has already implemented a work order and the call system is currently being worked on. LPA conducted interviews with R#2-4 LPA went over the alleged allegation with the residents and all informed LPA that the wait time for assistance many vary however, they receive the assistance on time. LPA conducted interviews with S#2-4 regarding the alleged allegation and all denied not responding to residents calls on a timely manner. Based on corroborating evidence the department has determined that the above allegations 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 was provided to Facility Administrator Schamone.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2