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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800190
Report Date: 10/29/2025
Date Signed: 10/29/2025 01:18:05 PM

Unsubstantiated


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
07/02/2025 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250702102709
FACILITY NAME:EASTVALE MANOR ASSISTED LIVING LLCFACILITY NUMBER:
331800190
ADMINISTRATOR:LUMBRIS, CARMELOFACILITY TYPE:
740
ADDRESS:11842 SILVER LOOPTELEPHONE:
(951) 427-1510
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 4DATE:
10/29/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Staff -Ruey Nono TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Due to staff neglect, resident sustained pressure injuries.
Staff caused bruises on resident.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Mary Rico and Sarina Ramirez conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with staff Ruey Nono and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, and record review.

For the allegation, Due to staff neglect, resident sustained pressure injuries. During staff interviews 4 out of the 4 staff stated no resident had sustained pressure injuries due to staff neglect. During record review, LPA observed R1 did not sustain pressure injuries at the facility.

For the allegation, Staff caused bruises on resident. During staff interviews, 4 out of the 4 staff stated they did not cause bruises on any resident. In addition, 2 out of the 4 staff stated that R1 had bruises prior to being admitted to the facility. During record review, LPA observed the facility staff had documented R1 bruises during their admission process. Furthermore, outside parties also confirmed R1 already had bruises prior to moving to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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 2
Control Number 56-AS-20250702102709
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: EASTVALE MANOR ASSISTED LIVING LLC
FACILITY NUMBER: 331800190
VISIT DATE: 10/29/2025
NARRATIVE
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Based on the evidence found during the investigation, the (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to staff Ruey Nono.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2