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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880818
Report Date: 09/17/2025
Date Signed: 09/17/2025 11:10:49 AM

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
10/31/2022 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221031145150
FACILITY NAME:DIVINE MANOR CARE INCFACILITY NUMBER:
361880818
ADMINISTRATOR:YADAV, SHREETAFACILITY TYPE:
740
ADDRESS:6367 MARBLE AVETELEPHONE:
(347) 449-2449
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY:6CENSUS: 5DATE:
09/17/2025
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Shreeta YadavTIME COMPLETED:
11:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed pressure ulcer while in care.
Facility were not ensure residents care needs were being met.
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 Administrator Shreeta Yadav and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Resident developed pressure ulcer while in care. Regarding the allegation stated above LPA conducted a review of records pertaining to Resident #1 during the review of records LPA observed that R#1 was admitted at Divine Manor on 9/9/2022 During further review LPA discovered based on Resident #1 documentation (pre-appraisal, physicians report), R#1 was admitted at the Facility with a stage 2 pressure ulcer already present. Furthermore, LPA observed that R#1 was receiving treatment for the wound by Home Health, documentation further indicated that no new ulcers were developed. In addition, LPA observed that R#1 was discharged on 9/29/2022. Furthermore, records also demonstrated that on 9/22/2022 per home health progress notes R#1 wound was improving based on treatment.

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

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
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 2
Control Number 56-AS-20221031145150
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: DIVINE MANOR CARE INC
FACILITY NUMBER: 361880818
VISIT DATE: 09/17/2025
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
Second allegation: Facility were not ensuring residents care needs were being met. Regarding the allegation stated above LPA conducted interviews with R#2, R#3, and R#4, LPA went over the allegation stated above and R#2-4, informed LPA that they have no concerns, and that the facility meets their care needs on the daily. In addition, R#2-4 informed LPA that they enjoy living at the facility and that they feel safe. LPA conducted interviews with S#1 and S#2 LPA went over the allegation stated above and staff #1-2 denied the allegation and informed LPA that staff always ensures that residents needs are always being met. 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 Administrator Shreeta Yadav at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2