366427230-3-21-2023-56-AS-KCLS-CQUTCS-20230413143711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366427230
Report Date: 03/21/2023
Date Signed: 03/21/2023 04:43:18 PM

Unsubstantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2023 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 56-AS-20230314095023

FACILITY NAME:	BLOOMINGTON CARE CENTER INC		FACILITY NUMBER:	366427230
ADMINISTRATOR:	ALLISON A. LAYGO		FACILITY TYPE:	735
ADDRESS:	17552 MAYWOOD ST		TELEPHONE:	(909) 421-2006
CITY:	BLOOMINGTON	STATE: CA	ZIP CODE:	92316
CAPACITY:	6	CENSUS: 4	DATE:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	02:58 PM
MET WITH:	Lilibeth Santos Caregiver		TIME COMPLETED:	04:41 PM

ALLEGATION(S):

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Staff did not keep the home free from odor
Staff did not keep the home clean

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility to commence a complaint investigation and deliver findings. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with caregiver Lilibeth Santos.

LPA toured the facility and there were there was five (5) bedrooms in total. There was one (1) room not occupied by a resident which is room #4 per the facility sketch. During the tour of the facility all clients bedrooms kitchen,bathrooms and family rooms were clean and free of oders.

Based on the investigation observations, the above finding is Unsubstantiated. A finding of unsubstantiated means although the allegations 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 and discussed with Lilibeth Santos at the conclusion of the visit and a copy was provided with appeal rights.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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