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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530028
Report Date: 11/30/2023
Date Signed: 11/30/2023 04:47:41 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
11/27/2023 and conducted by Evaluator Amber Coleman
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231127141748
FACILITY NAME:MADRONA MANORFACILITY NUMBER:
365530028
ADMINISTRATOR:KAUR, GULVARGFACILITY TYPE:
740
ADDRESS:821 EAST MADRONA STREETTELEPHONE:
(909) 341-5084
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:6CENSUS: 5DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Gulvarg Kaur, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff are illegally evicting the resident from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Madrona Manor, Residential Care Facility for the Elderly to initiate a complaint investigation into the allegation listed above. LPA introduced self and stated the purpose of the visit. LPA was greeted and granted entry by Administrator Gulvarg Kaur.

During today's visit, LPA interviewed staff and residents, completed a walkthrough of the facility, reviewed and collected pertinent documents. Staff interview revealed that the resident was never given a legal eviction notice. The notice was provided to the resident and his medical care plan as a request for relocation due to the resident's behaviors. LPA and Administrator discussed the difference between a legal eviction and a request of relocations. Resident interview revealed that the documentation provided was thought to be an eviction. LPA and resident discussed what an eviction is and complaince with the facility's house rules.

Please see LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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-20231127141748
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: MADRONA MANOR
FACILITY NUMBER: 365530028
VISIT DATE: 11/30/2023
NARRATIVE
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Based on information above, the allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. This report was reviewed, discussed, then provided to Facility Representative.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2