365530028-8-2-2025-56-AS-NBRN-DK8MKV-20250804094118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 365530028
Report Date: 08/02/2025
Date Signed: 08/02/2025 12:00:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
09/12/2024 and conducted by Evaluator Lavette Farlow

COMPLAINT CONTROL NUMBER: 56-AS-20240912145733

FACILITY NAME:	MADRONA MANOR		FACILITY NUMBER:	365530028
ADMINISTRATOR:	KAUR, GULVARG		FACILITY TYPE:	740
ADDRESS:	821 EAST MADRONA STREET		TELEPHONE:	(909) 341-5084
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	6	CENSUS:	DATE:	08/02/2025
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Gulvarg "Maya" Kaur, Administrator		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff abandoned resident
Staff yells at resident
Staff are not providing adequate food service to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to the facility to conclude the investigation and deliver the findings to the above-mentioned complaint. LPA was greeted and granted entry by Caregiver, Esperenza Duro, LPA informed Esperenza of the purpose of the visit and askd that she inform the administrator of my arrival. LPA later met with Administrator Gulvarg "Maya" Kaur during the visit. The investigation consisted of a tour, observations, interviews with residents and staff and record reviews.

Allegation 1: Staff abandoned resident. LPA interviewed 4 out of 4 residents in care and based on the interviews 4 out of 4 residents stated they have not felt abandoned and that their needs are being met by staff. LPA interviewed 2 out of 2 staff and based on the interviews with staff it was revealed that staff have not abandoned residents in care. LPA interviews with R1, and W1, it was revealed the Administrator made comments that made R1 and W1 believed R1 would not have placement while in the hospital. R1 was unable to give examples or express what was said due to illness. LPA, observed staff assisting other residents in care during visit.
***Continued LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240912145733

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MADRONA MANOR	FACILITY NUMBER: 365530028
	VISIT DATE: 08/02/2025

NARRATIVE

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Allegation 2: Staff yelled at residents. LPA interviewed four (4) residents in care. Four (4) out of four (4) residents stated that the staff were nice and they did not experience staff or administrators yelling at them. R1 and W1 stated the administrator yelled at them while R1 was in the hospital and trying to recover. It was reported the administrator made reference to R1 spending too much time in the hospital and she needs to move and administrator stated she already have someone ready to take R1 place.

Allegation 3: Staff are not providing adequate food service to residents. LPA Farlow interviewed four (4) out of four (4) residents in care. Four out of four residents stated the food was good and they were satisfied with the meals. Interviews with R2, R3 stated they enjoy the hot dogs, and hamburger meals. R1 stated they only provide coffee and muffins for breakfast, not a well-balanced meal. During today’s visit LPA observed the facility menu and sufficient food supply, for the number of residents in care per regulations.

Based on the information above, the allegations is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegations 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 Administrator Gulvarg "Maya" Kaur.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2025

LIC9099 (FAS) - (06/04)

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