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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366427230
Report Date: 08/24/2021
Date Signed: 08/24/2021 12:37:01 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2021 and conducted by Evaluator Christine Le
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210221092315
FACILITY NAME:BLOOMINGTON CARE CENTER INCFACILITY NUMBER:
366427230
ADMINISTRATOR:LAYGO, ANITAFACILITY TYPE:
735
ADDRESS:17552 MAYWOOD STTELEPHONE:
(909) 421-2006
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY:6CENSUS: 5DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lilbeth SantosTIME COMPLETED:
12:46 PM
ALLEGATION(S):
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Staff hit client resulting in back pain and scratches on the face.
Staff yells and calls names to the clients in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to deliver the findings of the above allegations. LPA met with direct care staff Lilibeth Santos. LPA spoke with the operations manager over the phone.

LPA toured the facility, conducted interviews, and reviewed facility files. The first allegation indicates that on 2/20/21 Staff 1 (S1) hit Client 1 (C1) which resulted in scratches on the client’s face and the client sustaining back pain. During the file review and interviews, LPA was informed that on 2/20/21 S1 and C1 got into a verbal and physical altercation. It was reported that there was growing tension between the two parties. Interviews in general reported that S1 was yelling at C1 as the staff alleged the client attacked him/her. During the file review and interviews, LPA was informed that S1 charged at the client, scratched C1’s face, and in response C1 bit the staff’s finger. S1 also utilized a broom to threaten and taunt the client. In response to this, another staff member intervened and placed themselves between the staff and client. The facility staff called 911 for C1 as the client sustained scratches on the face and was in pain. The second
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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 18-AS-20210221092315
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
RIVERSIDE, CA 92507

FACILITY NAME: BLOOMINGTON CARE CENTER INC
FACILITY NUMBER: 366427230
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2021
Section Cited
CCR
80072(a)(3)
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80072 PERSONAL RIGHTS (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or
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LPA observed that the licensee conducted in-service training to direct care staff in regards to the clients' personal rights on 2/8/21 and 4/20/21. Deficiency cleared during visit.
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other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met evidenced by: Based on file review & interviews, the
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DEF CONT'D licensee did not ensure C1’s personal rights were protected. LPA was informed that on 2/20/21 S1 & C1 got into a physical altercation which resulted in C1 sustaining scratches on his/her face and back pain. S1 also threatened C1 with a broom.
Type A
08/25/2021
Section Cited
CCR
80072(a)(1)
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80072 PERSONAL RIGHTS (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by:
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LPA observed that the licensee conducted in-service training to direct care staff in regards to the clients' personal rights on 2/8/21 and 4/20/21. Deficiency cleared during visit.
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Based on interviews, the licensee did not ensure the clients were treated with dignity and respect. LPA was informed that S1 yells at the clients in care and calls them ‘retarded’ and ‘stupid’.
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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: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210221092315
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
RIVERSIDE, CA 92507
FACILITY NAME: BLOOMINGTON CARE CENTER INC
FACILITY NUMBER: 366427230
VISIT DATE: 08/24/2021
NARRATIVE
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allegation indicates that S1 yells at the clients and call them names. LPA conducted interviews with staff and clients who in general reported that S1 yells at the clients (especially C1) and calls them ‘retarded’ and ‘stupid’. This poses an immediate health, safety, and personal rights risk to the clients in care. During the investigation, LPA was informed that the facility terminated S1’s employment after the incident. The licensee also conducted in-service training for direct care staff in regards to the clients' personal rights.

Based on LPA’s observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to the DSP.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3