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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423880
Report Date: 04/08/2025
Date Signed: 08/01/2025 10:24:27 AM

Substantiated


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
02/13/2025 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250213114405
FACILITY NAME:CORONA RCFEFACILITY NUMBER:
336423880
ADMINISTRATOR:JENNIFER D. MONTGOMERYFACILITY TYPE:
740
ADDRESS:2600 SOUTH MAIN STREETTELEPHONE:
(951) 736-4900
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:49CENSUS: 23DATE:
04/08/2025
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Administrator - Jennifer D. Montgomery TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff refused to accept resident back to the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Administrator Jennifer D. Montgomery and explained the purpose of the visit. The investigation consisted of staff interviews, record review and facility tour.

For the allegation, Staff refused to accept resident back to the facility.

During staff interview, 3 out of the 4 staff stated the on 2/12/2025 R1 had left the facility and attempted to come back to the facility that same day. The Administrator stated that on 2/12/2025 R1 had signed the self-voluntary moveout form and was no longer a resident.

During resident interviews, R1 stated they had no acknowledgement of what document they had signed. R1 informed LPA that on 2/12/2025 they had left the facility for an assessment and indicated facility staff had locked him out when they attempted to returned.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
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 3
Control Number 56-AS-20250213114405
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: CORONA RCFE
FACILITY NUMBER: 336423880
VISIT DATE: 04/08/2025
NARRATIVE
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LPA Rico had obtained facility footage, that demonstrated R1 had left the facility on 2/12/2025 at 10:25am and returned on 2/12/2025 at 11:45am. LPA Rico observed facility had refused to accept resident back to the facility, as resident attempted to gain entry.

During facility tour, LPA Rico observed R1 personal belongings had remained inside the facility. In addition, the facility did not provide a 30 day eviction notice to Community Care Licensing and resident did not provide a 30 day notice of move out. Furthermore, the self-voluntary document is not part of Facility Program Designed and is not approved by Community Care Licensing.

Based on the evidence gathered during today’s investigation, the one (1) allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met.



During today’s visit, one (1) deficiency were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Administrator Jennifer D. Montgomery, along with a copy of the appeal rights. Administrator Jennifer D. Monthgomery refused to signed document.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 56-AS-20250213114405
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: CORONA RCFE
FACILITY NUMBER: 336423880
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
04/09/2025
Section Cited
CCR
87468.2(a)(20)
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To be protected from involuntary transfers, discharges, and evictions.. state.. and relocation protections for residents. For purposes of this paragraph.. means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.
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The Administrator stated they will read the regulation cited 87468.2(A)(20) and will send a self-verification letter they have read and understood the regulation.
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This requirement wasn't met as evidenced by: Based on interviews, facility tour and video footage the Administrator refused to accept resident back to the facility which poses an immediate health, safety or personal rights risk to persons in care.
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POC due date 4/9/2025
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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: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3