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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 12/12/2025
Date Signed: 12/12/2025 05:10:10 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
12/05/2025 and conducted by Evaluator Edith Conchas
COMPLAINT CONTROL NUMBER: 56-AS-20251205105836
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: 58DATE:
12/12/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Executive Director, Schamone BardTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident sustained an injury as a result of a unwitnessed fall
Staff did not seek medical attention for residents in care
Staff does not ensure food served is of good quality
Staff does not ensure expired food is discarded from the facility
INVESTIGATION FINDINGS:
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On 12/12/2025, Licensing Program Analysts (LPA) Edith Conchas conducted an unannounced complaint visit to the property in order to initiate an investigation into the above allegation. The LPA met and discussed the purpose of the visit with Executive Director, Schamone Bard. The investigation consisted of interviews with the operator, staff and witnesses.

Reagarding allegation the Resident sustained an injury as a result of a unwitnessed fall, interview with witness 1 (W1) reveal resident 1(R1) fell and hit his head. Regarding the allegation Staff did not seek medical attention for residents in care, LPA interviewed 6 staff and confirmed resident did fall and did not seek medical attention only sat him back up on the chair. Regarding allegation Staff does not ensure food served is of good quality, interview with staff 2 (S2) reveal mold was observed in the bread. Regarding allegation Staff does not ensure expired food is discarded from the facility, intreview with staff 2 (S2) reveal the mold was observed on the bread after serving it to the resident.
Continue LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2025
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-20251205105836
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: 12/12/2025
NARRATIVE
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Based on interviews, and record review, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

During today’s visit, deficiency and a repeated violation civil penalty was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC9099, LIC9099C, LIC9099D, LIC421FC and appeal rights were discussed and provided to Executive Director, Schamone Bard
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20251205105836
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: 12/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2025
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care(g) (g) The licensee shall immediately telephone ...a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement is not met as evidenced by:
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Administrator will create a log book on designated hall person daily for all shifts to ensure observation is being done for patients safety and provide a copy to LPA by POC date and will conduct an in-service training with all staff on reporting unwitnessed falls and seeking medical attention.
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Based on interviews, the licensee did not comply with the section cite above by not calling 911 after falls with suspected head injury for R1 which poses an immediatel health, safety and personnal rights risk to persons in care.
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Type B
12/15/2025
Section Cited
CCR
87555(a)
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87555General Food Service Requirements(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs and... shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
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Administrator will create a log book for daily inspection of food upon arrrival of shift for cooks to complete daily and provide a copy to LPA by POC and will provide in-service training on food handling
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Based on interviews, the licensee did not comply with the section cite above by not serving mold to a resident. Which poses an potential health, safety and personnal rights 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: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3