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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366402583
Report Date: 11/05/2024
Date Signed: 11/05/2024 12:26:52 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
10/29/2024 and conducted by Evaluator Raquel Hernandez
COMPLAINT CONTROL NUMBER: 56-AS-20241029154509
FACILITY NAME:BROOKDALE NORTH EUCLIDFACILITY NUMBER:
366402583
ADMINISTRATOR:LISA TOFACILITY TYPE:
740
ADDRESS:1031 N EUCLID AVETELEPHONE:
(909) 391-2622
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY:140CENSUS: 63DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Buisness Office Manager Marcos RamosTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Unlawful eviction.
Staff not providing an accurate dosage of medication to resident.
Staff not allowing resident to have visitors.
Staff stealing money from resident.
INVESTIGATION FINDINGS:
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On 11/5/2024 Licensing Program Analysts (LPAs) Raquel Hernandez and Mary Rico conducted an unannounced visit to deliver findings on the allegations listed above. LPAs met with Business Office Manager Marcos Ramos and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and facility tour.

For the allegation, Unlawful eviction.

During record review, LPA's verified documentation for resident #R1 eviction notice. LPAs obtained a copy of 30 day notice issued to R1 on 12/19/2023 due to room and board payments. The 30 day notice was signed by R1 and dated 12/29/2023. S1 stated Adult Protective Services assisted with relocation of R1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
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 2
Control Number 56-AS-20241029154509
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: BROOKDALE NORTH EUCLID
FACILITY NUMBER: 366402583
VISIT DATE: 11/05/2024
NARRATIVE
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For the allegation, Staff not providing an accurate dosage of medication to resident.

LPAs Hernandez and Rico conducted (5) resident interviews and (4) staff interviews. During resident interviews, 5 out of the 5 residents stated the accurate dosage of medication is given to them. During staff interviews 4 out of the 4 staff stated an accurate dosage of medication is given to each resident.

For the allegation, Staff not allowing resident to have visitors.

LPAs conducted (5) resident interviews and (4) staff interviews. During resident interviews 5 out of the 5 stated the facility allows them to have visitors when they would like. During staff interviews 4 out of the 4 staff stated all residents are allowed to have visitors at the facility. Additionally, LPAs conducted a facility tour and observed visitor logs for the residents in the facility.

For the allegation, Staff stealing money from resident.

LPAs conducted (5) resident interviews and (4) staff interviews. During resident interview 5 out of the 5 residents stated no staff has stolen money or personal belongings from them. During staff interview 4 out of the 4 staff stated they have not stolen any money or personal belongings from the residents at the facility. Additionally, staff reported they have not witnessed or suspected any other staff at the facility has stolen any money or personal belongings from residents.


Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) (LIC9099C) was discussed and provided to Business Office Manager Marcos Ramos.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2