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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880964
Report Date: 12/09/2025
Date Signed: 12/09/2025 12:24:08 PM

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
04/28/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230428113629
FACILITY NAME:CADENCE AT RANCHO CUCAMONGAFACILITY NUMBER:
361880964
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:10459 CHURCH STREETTELEPHONE:
(909) 918-5546
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:117CENSUS: 115DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ashley Willett- AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for resident's serious injury.
Staff refused to assist resident with toileting.
Staff refused to assist resident with dressing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Ashley Willett and explained the purpose of the visit regarding the allegation stated above.

First allegation: Staff did not seek timely medical attention for residents’ serious injury.
Investigation was conducted by department staff which included review of records and witness interviews. R#1 Physician Report indicates that R#1 was diagnosed with Osteoporosis disorder, a disorder that is an increased risk of fractures. Based on R#1 records which revealed that R#1 had a history of Osteoporosis the facility should have provided immediate medical attention by transporting R#1 to a local hospital after the injury was reported and discovered. Based on R#1 record it was discovered that R#1 injury was found on March 2, 2023. However, R#1 did not receive an X-ray until March 4,2023 and six days later March 7,2023 R#1 had a splint applied.

Second allegation: Staff refused to assist resident with toileting.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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 6
Control Number 56-AS-20230428113629
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: CADENCE AT RANCHO CUCAMONGA
FACILITY NUMBER: 361880964
VISIT DATE: 12/09/2025
NARRATIVE
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Regarding the allegation “Staff refused to assist resident with toileting” the department received photo evidence of Resident #2 which demonstrated R#2 lying in bed uncovered wearing only a diaper brief that went down below R#2 waist. In addition, photo also demonstrated R#2 blanket to be sitting on the floor next to a used diaper.

Third allegation: Staff refused to assist resident with dressing. Regarding the allegation “Staff refused to assist resident with dressing” During the observation of photo evidence pertaining to Resident #2 LPA observed R#2 lying in bed uncovered wearing only a diaper brief that went down below R#2 waist and exposing resident. Photo demonstrated R#2 in a curled-up position undressed and without covers and or blankets. Based on the evidence gathered during the investigation, the above allegations are Substantiated.

A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 regulations 87465(2), Incidental Medical and Dental Care, 87468.1 Personal Rights of Residents in All Facilities (a)(1)(2) & (3), from division 6, chapter, article 6, is, being cited on the attached LIC 9099 D.

In addition, an immediate civil penalty of $500.00 was assessed, according to the Health and Safety Code 1548 (c). Furthermore, an additional civil penalty may be imposed by the Health and Safety Code
1569.49 (f).

An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to the Facility Administrator at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 56-AS-20230428113629
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: CADENCE AT RANCHO CUCAMONGA
FACILITY NUMBER: 361880964
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2025
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 of the entire "Incidental Medical and Dental Care" regulation and provide training to all care staff pertaining to the regulation stated above. The licensee will email LPA a statement of understading and will provide a copy of the training sign in sheet signed by all care staff by POC date.
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Based on observation, interviews and record review the licensee did not provide medical assistance on a timely manner for R#1 which poses an immediate Health, Safety, or Personal Rights risk for persons in care.
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Type B
12/26/2025
Section Cited
CCR
87468.1(a)(1)(2)
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Personal Rights of Residents in All Facilities 87468.1...(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:...(1) To be accorded dignity in their personal relationships with staff, residents, and other persons...(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidence by:
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Licensee has agreed to read of the entire "Personal Rights of Residents in All Facilities" regulation and provide training to all care staff pertaining to the regulation stated above. The licensee will email LPA a statement of understading and will provide a copy of the training sign-in sheet signed by all care staff by POC date 12/26/25.
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Based on observation, interviews and record review the licensee did not follow Personal Rights Regulation for R#2 which poses an immediate Health, Safety, or Personal Rights risk for 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: 12/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 56-AS-20230428113629
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: CADENCE AT RANCHO CUCAMONGA
FACILITY NUMBER: 361880964
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2025
Section Cited
CCR
87468.1(3)
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Personal Rights of Residents in All Facilities 87468.1...(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Licensee has agreed to read of the entire "Personal Rights of Residents in All Facilities" regulation and provide training to all care staff pertaining to the regulation stated above. The licensee will email LPA a statement of understading and will provide a copy of the training sign-in sheet signed by all care staff by POC date 12/26/25.
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Based on observation, interviews and record review the licensee did not follow Personal Rights Regulation for R#2 which poses an immediate Health, Safety, or Personal Rights risk for 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: 12/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
04/28/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230428113629

FACILITY NAME:CADENCE AT RANCHO CUCAMONGAFACILITY NUMBER:
361880964
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:10459 CHURCH STREETTELEPHONE:
(909) 918-5546
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:117CENSUS: 115DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ashely Willett- AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
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9
Resident sustained a fracture while in care due to licensee neglect.
Staff handled resident in a rough manner causing injury.
Staff left resident with soiled bedding.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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10
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Ashely Willett and explained the purpose of the visit regarding the allegations stated above.

First allegation: Resident sustained a fracture while in care due to licensee neglect.
Investigation was conducted by department staff which consisted of reviews of records along with witness interviews. Evidence shows on March 1, 2023, staff observed during a routine room check R#1 to be in client’s bedroom, sleeping between the hours of 10:00 pm-10:30 pm. It was reported during the routine check no injuries on R#1 (L) were observed or suspected. However, on March 2, 2023, around the hours of 06:45 am an injury was discovered on R#1 (L) lower arm. Reports also indicated that on March 2,2023 between the hours of 06:45 am R#1 informed staff about the injury on R#1 arm. Investigation could not show how R1 sustained the injury to resident’s left lower arm.

Second allegation: Staff handled resident in a rough manner causing injury.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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 6
Control Number 56-AS-20230428113629
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: CADENCE AT RANCHO CUCAMONGA
FACILITY NUMBER: 361880964
VISIT DATE: 12/09/2025
NARRATIVE
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Regarding the allegation “Staff handled resident in a rough manner causing injury. LPA conducted a review of record upon the review of records LPA discovered that Resident#1 did not indicate to staff or report to staff that resident’s injury was caused by staff or that staff had handled R#1 in a rough manner causing an injury. In addition, LPA discovered that based on interviews R#1 reported the injury to staff. LPA conducted interviews with R#3-6 LPA went over the alleged allegation with residents and all denied being handled in a rough manner by staff. In addition, all residents also denied witnessing staff handling residents in a rough manner. LPA conducted interviews with S#2-5 LPA went over the alleged allegation with staff and all denied handling residents in a rough manner. In addition, S#2-5 also denied witnessing staff handle resident in a rough manner or causing injuries to residents in care.

Third allegation: Staff left resident with soiled bedding.
Regarding the allegation “Staff left resident with soiled bedding” Based on observation and the review if R#2 photo LPA could not determine if R#2 bedding was soiled. Based on image LPA could not determine if R#2 bedding was soiled as the image did not display R#2 bedding to appear wet. LPA conducted interviews with R#3-6 LPA went over the alleged allegation with R#3-6 and all denied being left on soiled bedding. LPA conducted interviews with S#2-5 LPA went over the alleged allegation with staff and all denied leaving residents bedding wet or soiled. S#2-5 informed LPA that the facility provides housekeeping who changes residents sheets and conducts laundry service once a week and or as needed. Based on corroborating evidence the department has determined that the above allegations are 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 Ashely Willett.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6