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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 11:55:48 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
10/30/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241030093600
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:
12:15 PM
ALLEGATION(S):
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Staff did not seek timely medical care for resident in care
Staff did not notify resident's responsible person of resident's change of condition
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, observations, and review of records.

First allegation: Staff did not seek timely medical care for resident in care. Regarding the first allegation “Staff did not seek timely medical care for resident in care” LPA conducted an interview with Facility Administrator LPA was informed by Facility Administrator that Resident#1 had sustained an unwitnessed fall on 9/22/2024. Administrator informed LPA that paramedics were called to evaluate resident, and R#1 declined to be taken to the hospital. Administrator informed LPA that after the incident Resident #1 was not able to fully lift their arm. Administrator informed LPA that Resident#1 remained in that unable state for approximately a week before resident was taken to the hospital by R#1 Responsible Party.

Second allegation: Staff did not notify resident's responsible person of resident's change of condition.
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 5
Control Number 56-AS-20241030093600
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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Regarding the allegation “Staff did not notify resident's responsible person of resident's change of condition” LPA conducted an interview with Facility Administrator who informed LPA that Resident #1 had sustained an unwitnessed fall on 9/22/2024. In addition, Administrator informed LPA that staff noticed that R#1 was not able to fully lift their arm up for about a week. During the interview LPA was informed by the administrator that R#1 was taken to the hospital by R#1 responsible party, who later was informed by Kaiser, that R#1 had sustained a Hemerus Fracture due to an accidental fall R#1 sustained on 9/22/2024. Based on the interviews and evidence gathered above allegations are Substantiated.

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, 87465 (2) Incidental Medical and Dental Care, 87411 (a) Personnel Requirements – General, 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 5
Control Number 56-AS-20241030093600
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 A
12/05/2024
Section Cited
CCR
87465(2)
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Incidental Medical and Dental Care... 87465... (2)...The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.
This requirement is not met as evidence by:
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Licensee has agreed to read over “Incidental Medical and Dental Care” regulation and provide training to staff all staff regarding the regulation. Licensee will provide LPA Guerrero with a copy of training signed and acknowledged by all staff by POC date 12/5/2024.
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Based on interviews, record review, the licensee did not ensure Resident #1 received medical care on a timely manner, which poses a Health, Sefety, or Personal Rights risk to persons in care.
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Type A
12/05/2024
Section Cited
CCR
87411(a)
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Personnel Requirements – General... 87411.... (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidence by:
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Licensee has agreed to read over “Personnel Requirements – General” regulation and provide training to staff all staff regarding the regulation. Licensee will provide LPA Guerrero with a copy of training signed and acknowledged by all staff by POC date 12/5/2024.
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Based on interviews, record review, the licensee did not follow "Personnel Requirements" to detect Resident #1 change of condition on a timely manner, which poses a 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 5
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
10/30/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241030093600

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:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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, observations, and review of records.

First allegation: Resident sustained unexplained injuries while in care. Regarding the allegation “Resident sustained unexplained injuries while in care” LPA conducted interview with Facility Administrator who inform LPA that Resident #1 sustained an accidental fall on 9/22/2024. During record review LPA discovered that R#1 sustained scrapes and after further evaluation completed by Kaiser it was discovered that R#1 sustained a Hemerus Fractur. A fracture which resulted on R#1 to sustain bruising. Through review of records LPA discovered that injuries were not a result of neglect or abuse done by staff, but rather through an accidental fall R#1 sustained on 9/22/2024. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated.
Unsubstantiated
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: 4 of 5
Control Number 56-AS-20241030093600
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
1
2
3
4
5
6
7
8
9
10
11
12
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16
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Unsubstantiated; meaning that 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.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Clarita Pereabras at the end of the visit.
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: 5 of 5