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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360908378
Report Date: 12/04/2024
Date Signed: 12/04/2024 10:14:49 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
11/26/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241126113036
FACILITY NAME:ARCADIAN SHORES MANORFACILITY NUMBER:
360908378
ADMINISTRATOR:RITA HERRERAFACILITY TYPE:
740
ADDRESS:2620 ARCADIAN SHORES ROADTELEPHONE:
(909) 923-1428
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY:6CENSUS: 3DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Clarita Pereabras-CaregiverTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Facility staff do not ensure facility stove is in good repair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Caregiver Clarita Pereabras and explained the purpose of the visit. The investigation consisted of interviews and observations.

First allegation: Facility staff do not ensure facility stove is in good repair. Regarding the first allegation “facility staff do not ensure facility stove is in good repair” LPA conducted an inspection on facilities appliances and LPA discovered that the stove oven was in despair. LPA conducted an interview with Staff#1 who informed LPA that the oven has been out for approximately two-months. LPA tested the top stove burners and observed that all four burners were in working condition. LPA conducted an interview with Facility Administrator who informed LPA that a new stove has been purchased. Based on the evidence along with the observation, the above allegation Substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
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-20241126113036
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: ARCADIAN SHORES MANOR
FACILITY NUMBER: 360908378
VISIT DATE: 12/04/2024
NARRATIVE
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Substantiated: A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, 87303 Maintenance and Operation, from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights. to Facility Caregiver Clarita Pereabras.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20241126113036
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: ARCADIAN SHORES MANOR
FACILITY NUMBER: 360908378
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
CCR
87303
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87303 Maintenance and Operation....
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidence by:

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Licensee has agreed to read over “Maintenance and Operation” regulation and provide training to staff all staff regarding the regulation and ensuring that facility shall be always in good repair. Licensee will provide LPA Guerrero with a copy of training signed and acknowledged by all staff by POC date 12/13/2024. In addition, licensee will also provide pictures/and or invoices of the stove being repaired or replaced by the POC date provided
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Based on observation, interviews, the licensee did not ensure facility stove oven to be in good repairs according to Maintenance and Operation regulation, which can pose a potential health, Safety, or Personal Rights risk to persons in care.
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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: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3