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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366427230
Report Date: 04/07/2023
Date Signed: 04/11/2023 12:30:27 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
, 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 INCFACILITY NUMBER:
366427230
ADMINISTRATOR:ALLISON A. LAYGOFACILITY TYPE:
735
ADDRESS:17552 MAYWOOD STTELEPHONE:
(909) 421-2006
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY:6CENSUS: 4DATE:
04/07/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Cielita Ravelo Staff TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility door is in disrepair
Staff did not provide daily activities for residents
Staff are not adequately trained
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 Cielita Ravelo.

LPA toured the facility which has five (5) bedrooms in total. There was one (1) room not occupied by a resident which is room #4 per the facility sketch. All bedrooms with exiting doors were checked to see it they could be closed without force. The wooden door with glass pain windows in room #3 could not be closed with ease. The caregiver said that the prior resident kicked the door which has caused the door to be warped/bent at the bottom which does not allow the door to be closed completely.

LPA requested to see current training documents for all staff members and activity schedules Cielita stated that she did not have any staff filesor schedules available for LPA to review during the visit because she was making adjustments to the files outside of the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
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 4
Control Number 56-AS-20230314095023
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
, CA 92507
FACILITY NAME: BLOOMINGTON CARE CENTER INC
FACILITY NUMBER: 366427230
VISIT DATE: 04/07/2023
NARRATIVE
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 Ceilta was informed that all facility files should be available for review during visits this includes schedules, personnel, and residents files.

Based on the evidence gathered during the investigation interviews and observations, deficiencies have been issued and the allegations are found to be Substantiated.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and discussed with Cielita Ravelo at the conclusion with the appeal rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20230314095023
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
, CA 92507

FACILITY NAME: BLOOMINGTON CARE CENTER INC
FACILITY NUMBER: 366427230
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2023
Section Cited
CCR
85066(a)-(c)
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85066- Personnel Records
(a) In addition to Section 80066, the following shall apply.(b) A dated employee time schedule shall be developed at least monthly, shall be displayed conveniently for employee ...
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The licensee has agreed to read the cited regulation to it's entirety and provide a signed written statement of understanding of the regulation(s)cited to ensure that the files are complete and avaliable for LPA's review at all times. The licensee with provide this statement by the POC date of 4/11/2023
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This requirement is not met as evidenced by:
The licensee did not ensure that the staff files were avaliable/accessable for LPA review at the time of the visit.
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Type B
04/11/2023
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
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The licensee has agreed to replace the door to ensure that it can be completley closed and without force. The licensee will provide copy of invoice and picture of the new door by the POC date of 4/11/2023
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The licensee did not ensure that the exit door leading to the backyard in room #3 could be closed with ease. The wooden door is warped/bent at the bottom which does not allow the door to be closed completely.
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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: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20230314095023
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
, CA 92507

FACILITY NAME: BLOOMINGTON CARE CENTER INC
FACILITY NUMBER: 366427230
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2023
Section Cited
CCR
85079(a)(1)(2)
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85079 Activities
(a) (1) (2) The licensee shall ensure that planned recreational activities, which include the following, are provided for the clients
:This requirement is not met as evidenced by:
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The licensee has agreed to provide residents with activities examples: cards, puzzles, games etc. that can be done as a group or independently. Licensee will provide a written statement of understanding of the regulation and provide pictures of available activities for the residents to engage in
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The staff could not provide a schedule of actives or show LPA activities that are available to residents in care. LPA did not observe any activities that could be done as a group or independently examples( games, puzzles, cards...)
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while at the home. The licensee with provide this statement and pictures by the POC date of 4/11/2023



**this an amendment issued on 4/7/2023**
CCR
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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: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4