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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 09/16/2026
Date Signed: 09/16/2026 05:16:25 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
06/05/2026 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260605125413
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:0CENSUS: 50DATE:
09/16/2026
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Michelle Reyes- Business office ManagerTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff did not ensure that the residents received proper assistance with the self-administration of insulin
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver the investigative findings. LPA met with Business office Manager Michelle Reyes and explained the purpose of the visit regarding the allegations stated above.

First Allegation: Staff did not ensure that the resident received proper assistance with the self-administration of insulin. Regarding the allegation stated above, LPA conducted a review of R#1’s records. During the record review, LPA discovered that R#1 was admitted to Rose Garden Residential Care on 5/21/2026. According to R#1’s Preplacement Appraisal, R#1 was diagnosed with Type 2 diabetes and was insulin dependent. Further review of R#1’s records, including the Physician Report, indicated that R#1 was unable to independently administer medication and was not capable of self-administering injections. LPA reviewed R#1’s Medication Administration Record (MAR) and identified inconsistencies regarding the administration and documentation of R#1’s insulin. According to the MAR, R#1 began receiving insulin on 6/1/2026.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
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-20260605125413
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2026
Section Cited
CCR
87465(a)(1)(4)
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87465 Incidental Medical and Dental Care…. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following…. (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents…. (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidence by:
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The licensee has agreed to read regulations:
87465 Incidental Medical and Dental Care and provide training to all care staff addressing the regulation and addressing the importance of obtaining medication orders, refills, on time. The Licensee will also address the importance of how to properly administer medication according to residents’ medication orders. The Licensee will provide LPA with proof of trainings singed and dated by all staff. Training will be provided by POC date 9/22/2026.
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Based on review of records, the licensee did not adhere to the regulation stated above by not ensuring R1 received their insulin as indicated in their medical report, which poses an immediate health, safety, or personal rights risk to 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.
SUPERVISOR'S NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20260605125413
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: 09/16/2026
NARRATIVE
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However, R#1 had been admitted to Rose Garden Residential Care on 5/21/2026, and the MAR did not indicate that R#1 was receiving insulin between the admission date and 6/1/2026. Furthermore, upon review of R#1’s MAR, LPA observed entries dated 5/28/2026, 5/29/2026, 5/30/2026, and 5/31/2026 stating, “Physically unable to take.” The entries did not provide an explanation or indicate the specific reason R#1 was documented as physically unable to take the medication. LPA conducted interviews with S#1, S#2, and S#3 regarding the allegation. Staff #1-3 denied the allegation and stated that residents who are insulin dependent may independently administer their own insulin with minimal to no assistance. Staff #1-3 also denied administering insulin to residents and acknowledged that only licensed professionals may administer insulin via injection. Staff #1 informed LPA that the facility had been experiencing ongoing communication issues with R#1’s family regarding obtaining medication orders for R#1. Based on the record review and interviews conducted, LPA determined that the allegation that staff did not ensure R#1 received proper assistance with the self-administration of insulin is Substantiated. A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 Regulations, from division 6, chapter, article 6, is, cited on the attached LIC 9099 D.

An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Business office Manager Michelle Reyes at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3