<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800198
Report Date: 07/07/2021
Date Signed: 07/07/2021 12:59:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/28/2021 and conducted by Evaluator Natalie Gayoso
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210628104901
FACILITY NAME:MGB CARMEL MANORFACILITY NUMBER:
361800198
ADMINISTRATOR:BERNAL, GLENNFACILITY TYPE:
740
ADDRESS:457 WEST 13TH STREETTELEPHONE:
(909) 982-4786
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 5DATE:
07/07/2021
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Eladia PlenosTIME COMPLETED:
01:12 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not dispense medication according to prescription
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Natalie Gayoso and Jesse Gardner conducted an unannounced visit to the facility to commence an investigation for the above allegations. LPAs were greeted and allowed entrance by caregiver Eladia Plenos. Administrator Glenn Bernal was contact and LPAs explained the purpose of today's visit.

The investigation consisted of record revews and observations. The allegation indicated staff did not dispense medication according to prescription. LPAs reviewed residents medications and observed that 2 of Resident #5's medications were not dispensed as prescribed by their physician. LPAs also observed that residents PM medications were being removed from the bubble packs and placed in pill boxes to be administered later in the evening.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Natalie Gayoso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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 18-AS-20210628104901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
VISIT DATE: 07/07/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on LPAs observations and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 & Chapter 8, are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Natalie Gayoso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210628104901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited
CCR
87465(c)(2)
1
2
3
4
5
6
7
Incidental Medical and Dental Care(c)(2):Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator shall retrain staff on medication management and provide LPA with sign in sheet by POC date of 7/8/21. Licensee/Administrator will immediately stop using pill organizers to dispense medication.
8
9
10
11
12
13
14
Based on observation and record reviews, the licensee did not comply with in 4 out of 5 residents medication were not dispensed as prescribed and PM medications were placed in pill boxes. This poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Karen Clemons
LICENSING EVALUATOR NAME: Natalie Gayoso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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
CCLD Regional Office, 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
06/28/2021 and conducted by Evaluator Natalie Gayoso
COMPLAINT CONTROL NUMBER: 18-AS-20210628104901

FACILITY NAME:MGB CARMEL MANORFACILITY NUMBER:
361800198
ADMINISTRATOR:BERNAL, GLENNFACILITY TYPE:
740
ADDRESS:457 WEST 13TH STREETTELEPHONE:
(909) 982-4786
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 5DATE:
07/07/2021
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Eladia PlenosTIME COMPLETED:
01:12 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not following doctors orders
Facility lacks awake staff during the night shift with residents with Dementia
Staff threatened resident with eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Natalie Gayoso and Jesse Gardner conducted an unannounced visit to the facility to commence an investigation for the above allegations. LPAs were greeted and allowed entrance by caregiver ELadia Plenos. Administrator Glenn Bernal was contact and LPAs explained the purpose of today's visit.

LPAs conducted interviews with relevant parties. The first allegation indicates staff are not following doctors orders. Interviews with staff stated Resident #1 (R1) was able to do their own ADLs and staff would assist as needed. LPAs reviewed R1's physicians report and observed R1 needs standby assistance with dress/grooming self and some assitance for hard to reach areas for bathing.

The second allegation indicates facility lacks awake staff during the night shift with residents with dementia. Interviews with staff revealed that there are 2 caregivers during the NOC shift. 1 caregiver sleeps while the other is awake and checks on the residents every 2 hours.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Natalie Gayoso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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 18-AS-20210628104901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
VISIT DATE: 07/07/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The third allegation indicates staff threaten resident with eviction. Interview with Administrator stated that R1 was never threaten to be evicted. The facility was not able to met the R1's families demands and Administrator advised R1's family to look for another facility that could provide services the family were requesting.

Based on interviews, which were conducted, the allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of this report, LIC 9099D, and Appeal Rights was provided to the caregiver Ranulfa Regis.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Natalie Gayoso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5