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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366427230
Report Date: 06/11/2025
Date Signed: 06/11/2025 09:57:47 AM

Unsubstantiated


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
04/01/2025 and conducted by Evaluator Eldin Serrano
COMPLAINT CONTROL NUMBER: 56-AS-20250401111912
FACILITY NAME:BLOOMINGTON CARE CENTER INCFACILITY NUMBER:
366427230
ADMINISTRATOR:JUDELSON ENRIQUEZFACILITY TYPE:
735
ADDRESS:17552 MAYWOOD STTELEPHONE:
(909) 421-2006
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY:6CENSUS: 5DATE:
06/11/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lilibeth Santos, Direct Support ProfessionalTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Facility staff abandoned resident at the hospital
INVESTIGATION FINDINGS:
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On 6/11/2025 at 9:10 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegation. LPA Serrano explained the purpose of the visit to a Direct Support Professional Lilibeth Santos. Administrator is unavailable during the visit. The investigation consisted of file review, interviews with staffs as well as observation.

Allegation: Facility staff abandoned resident at the hospital – Based on record review and interview with administrator and Inland Regional Center (IRC) staff, they both stated that client #1 (C1) is a temporary/emergency placement. C1 was admitted at the facility after being discharged from Pomona Valley Hospital (PVH) on 3/28/2025 (Friday) going towards the weekend. C1 was admitted to Kaiser Permanente emergency on the same day due to health issues. Based on the interview with IRC staff, C1 stayed in the hospital from 3/28/2025-4/04/2025 and was discharged and was placed in a more suitable facility for C1 level of care.
*** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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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Control Number 56-AS-20250401111912
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: BLOOMINGTON CARE CENTER INC
FACILITY NUMBER: 366427230
VISIT DATE: 06/11/2025
NARRATIVE
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During the investigation, LPA did not find evidence to corroborate the allegations.

Based on the evidence, the allegation mentioned above is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to DSP Lilibeth Santos.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
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