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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800198
Report Date: 12/03/2024
Date Signed: 12/03/2024 02:05:51 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
11/20/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241120095631
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: 6DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Eladia Plenos-CaregiverTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff consume liquor while on shift
Staff do not have fingerprint clearance
Staff lock facility doors to prevent residents from leaving
Staff insert suppositories to residents in care
Staff did not complete required trainings
Staff did not maintain resident records
Residents are not provided proper food service
Staff did not ensure resident’s diapering needs were met
Staff did not provide adequate medication assistance to residents in care
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 Eladia Plenos and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, staff consume liquor while on shift. Regarding the first allegation “Staff consume liquor while on shift” LPA conducted a walkthrough of the facility, LPA inspected kitchen cabinets, appliances, along with kitchen pantry, and liquor was not observed during the inspection. LPA conducted interviews with residents regarding staff consuming liquor while on shift, all residents denied witnessing staff consume liquor while providing care. In addition, residents also denied smelling liquor odor on staff. LPA conducted interviews with staff regarding staff consuming liquor while on shift. All staff denied consuming or storing liquor at the facility. Furthermore, staff also denied witnessing other staff consume liquor while providing care to residents.

Second allegation, Staff do not have fingerprint clearance.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
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 9
Control Number 56-AS-20241120095631
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: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
VISIT DATE: 12/03/2024
NARRATIVE
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. Regarding the allegation “Staff do not have fingerprint clearance” LPA retrieved a facility roster via Guardian Background System, and observed that Staff #1, Staff#2, and Staff#3, that were currently working at the facility all were eligibly cleared. LPA conducted a file review for Staff 1-3 and discovered that all clearance records were on file.

Third allegation, Staff lock facility doors to prevent residents from leaving. Regarding the allegation “Staff lock facility doors to prevent residents from leaving” LPA conducted a walkthrough of the facility and inspected six out of six resident’s bedrooms along with resident’s doorknobs and observed that no laches or childproof locks were in place. In addition, LPA conducted an inspection on all doors along with emergency exists and witnessed that no latches or childproof locks were in place. LPA conducted interviews with residents regarding the allegation “Staff locking facility doors to prevent residents from leaving” all residents denied being locked or prevented from leaving the facility. LPA conducted interviews with staff regarding the alleged allegation, and all denied locking or preventing residents from leaving the facility.

Fourth allegation, Staff insert suppositories to residents in care. Regarding the allegation” Staff insert suppositories to residents in care” LPA conducted interviews with staff and all staff denied utilizing or inserting suppositories to residents. In addition, all staff informed LPA that suppositories are not kept or stored at the facility. LPA conducted interviews with residents, and all denied having suppositories inserted by staff. LPA conducted a medication inspection and discovered that no suppositories are being stored.

Fifth allegation, Staff did not complete required trainings. Regarding the allegation “Staff did not complete required trainings” LPA conducted a full staff file review and observed that training was completed LPA also observed certificates of completion to be on for all staff.

Sixth allegation, Staff did not maintain resident records. Regarding the allegation “Staff did not maintain resident records” LPA conducted a file review of all resident records and discovered that all required documentation for six out of six residents were on file based on Title 22 Residential Care Facility for Elderly (RCFE).

Seventh allegation, Residents are not provided proper food service. Regarding the allegation “Residents are not provided proper food service” LPA conducted an inspection on facilities food supply. During the inspection LPA discovered that the facility had adequate amount of food supply to meet resident needs. In addition, LPA observed that all food including canned goods sustained current shelf life. LPA conducted interviews with residents where five out of six residents stated that that the food is okay and have no concerns. Resident#6 stated that the breakfast that is served is good, and that Resident#6 purchases and stores their own lunch and dinner.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 56-AS-20241120095631
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: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
VISIT DATE: 12/03/2024
NARRATIVE
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Eighth allegation, Staff did not ensure resident’s diapering needs were met. Regarding the allegation “Staff did not ensure resident’s diapering needs were met” LPA conducted interviews with residents pertaining to the allegation resident’s diaper needs were not met. Six out of six residents denied the allegation and stated that staff completes their diaper needs and change residents on a timely manner.

Ninth allegation, Staff did not provide adequate medication assistance to residents in care, Regarding the alleged allegation. LPA conducted interviews with residents and six out of six residents stated that they receive medication on a timely manner. In addition, all residents stated that medication is always given and not withheld by staff. LPA conducted a file review of residents MAR records and observed that all medication is being distributed and managed correctly by staff.

Tenth allegation, Staff threatened residents in care. Regarding the allegation “Staff threatened residents in care” LPA conducted interviews with residents pertaining to the alleged allegation and six out of six residents denied being threatened or mistreated by staff. In addition, all residents denied witnessing staff threat other residents in care. LPA conducted interviews with staff regarding the allegation stated above, all staff denied threatening or mistreating residents in care. In addition, staff also denied witnessing other staff threat or mistreat residents in care.

Eleventh allegation, Staff did not ensure sufficient food items were available at the facility for residents in care. Regarding the allegation stated above. LPA conducted an inspection on facilities food supply. During the inspection LPA discovered that the facility had adequate amount of food supply to meet resident needs. LPA conducted interviews with residents and six out of six residents stated that the food provided is fulfilling and have no issues with food or snack supply.

Twelfth allegation, Staff yelled at residents in care. Regarding the allegation “Staff yelled at residents in care” LPA conducted interviews with residents pertaining to the allegation stated above and six out of six residents denied being yelled at by staff. In addition, all residents denied witnessing staff yell at residents in care. LPA conducted interviews with staff regarding the allegation stated above, all staff denied yelling at residents in care. In addition, staff also denied witnessing other staff yell at residents in care.

Thirteenth allegation, Staff did not assist residents that sustained falls. Regarding the allegation” Staff did not assist residents that sustained falls” LPA conducted interviews with residents, and all denied staff not assisting residents with transfers. All residents also stated that caregivers are very involved with helping residents who are non-ambulatory. Furthermore, during interviews residents denied witnessing residents sustain falls and not being assisted by staff

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 56-AS-20241120095631
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: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
VISIT DATE: 12/03/2024
NARRATIVE
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Fourteenth allegation, centrally stored medications are accessible to residents in care. Regarding the allegation “Centrally stored medications are accessible to residents in care” LPA conducted a walkthrough of the facility during the walkthrough LPA discovered a black metal cabined located across bedroom #6 that was locked and secure. LPA checked cabinet to ensure that the cabinet was locked and secured. During the inspection facility staff opened the cabinet with a key (no magnet) and demonstrated to LPA that medication cabinet remains locked and inaccessible to residents in care.

Fifteenth allegation, Staff do not have a fire evacuation plan at the facility. Regarding the allegation “Staff do not have a fire evacuation plan at the facility” LPA conducted a walkthrough of the facility and observed proper fire evacuation posters posted around the facility. LPA conducted a record review and observed that the last evacuation was completed in November. LPA observed exit signs throughout the facility. In addition, staff informed LPA that the main entry door is their primary exit in case of a fire. LPA observed that five out of six bedrooms have an exit door.

Sixteenth allegation, Staff do not have an infection control plan at the facility. Regarding the allegation “Staff do not have an infection control plan at the facility” LPA conducted a record review and observed that facility had an infection control plan in place that was current. In addition, LPA observed proper postings throughout the facility that indicated the preventions and the spreads of infections and illnesses.

Seventeenth allegation, Staff are not following reporting requirements. Regarding the allegation “Staff are not following reporting requirements” LPA conducted interviews with staff who informed LPA that Special Incident Reports, are faxed to CCL office when pertaining to any incident involving the residents in care. Staff in formed LPA that the lates report was faxed a few days ago regarding Upland Police Department conducting a wellness check.

Eighteenth allegation, Staff left residents unattended. Regarding the allegation “Staff left residents unattended” LPA conducted interviews with residents regarding the allegation stated above all six residents denied being left alone or unattended at the facility. LPA conducted interviews with regarding the alleged allegation all staff denied leaving residents in care unattended or unsupervised. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

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 Caregiver Eladia Plenos at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 9
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
11/20/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241120095631

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: 6DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Eladia Plenos-CaregiverTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff facility records are falsified
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 Eladia Plenos and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff facility records are falsified. Regarding the allegation "Staff facility records are falsified" LPA conducted a Frist Aid & CPR verification through Amercian Healthcare Academy the agency used by the facility to certify staff. LPA went through verifycertificate and discoverd that two numbers associated to the CPR card that pertained to Staff #1 and Staff #2 did not match on what the verifaction on certificate displayed. In addition, both numbers associated were listed as expired on the verification website when on file facility has the experation date of 2026. . Based on the evidence gathered during the investigation, the above allegations are Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 56-AS-20241120095631
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: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
VISIT DATE: 12/03/2024
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, 87207 False Claims, 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 Asenath Lainez-Munoz.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 56-AS-20241120095631
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: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/13/2024
Section Cited
CCR
87207
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87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidence by:
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Licensee has agreed to read over False claims regulation and ensure that all staff has a valid CPR & First Aid certification. Licensee with provide LPA with a signed acknowledgement of understanding and provide a copy of all certifications including the signed acknowledgment to LPA Guerrero by POC date 12/13/2024.
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Based on record review, the licensee did not ensure that Staff #1 and Staff #2 had valid First Aid & CPR card, which poses an immediate 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: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9
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
11/20/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241120095631

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: 6DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Eladia Plenos-CaregiverTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
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9
Staff did not inform resident’s physician of resident’s change of condition
Staff refuse to call an ambulance for residents in care
Staff did not prevent residents from engaging in inappropriate interactions
INVESTIGATION FINDINGS:
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2
3
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5
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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 Plenos and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff did not inform resident’s physician of resident’s change of condition. Regarding the allegation “Staff did not inform resident’s physician of resident’s change of condition” LPA conducted a record review and LPA discovered that Resident #1 who was listed on the allegation does not live at the facility or has received care at the facility. LPA inspected Facilities Resident Roster and discovered that Resident #1 is not a resident at the facility.

Second allegation, Staff refuse to call an ambulance for residents in care. Regarding the allegation Staff refuse to call an ambulance for residents in care” LPA conducted interviews with staff and all informed LPA that Resident #1 does not live at the facility nor has ambulance request been needed at the facility.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 56-AS-20241120095631
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: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
VISIT DATE: 12/03/2024
NARRATIVE
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Third allegation, Staff did not prevent residents from engaging in inappropriate interactions. Regarding the allegation “Staff did not prevent residents from engaging in inappropriate interactions” LPA conducted a resident file review and discovered that Resident #2, Resident #3, Resident #4, and Resident #5, that were listed in the alleged allegation are not residents that have ever lived at the alleged facility. Based on the available information, LPA found the complaint allegation is Unfounded.

Unfounded: A find of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted where this report was discussed, and a copy provided to Facility Caregiver Eladia Plenos.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9