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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366402583
Report Date: 12/10/2025
Date Signed: 12/10/2025 01:07:14 PM

Substantiated


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
12/04/2025 and conducted by Evaluator Raquel Hernandez
COMPLAINT CONTROL NUMBER: 56-AS-20251204105800
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: DATE:
12/10/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff does not keep resident’s urinal clean.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the purpose of deliever findings for the above allegations. LPA met with Administrator Logan Harrison and explained today's visit.

For the allegation, Staff does not keep resident’s urinal clean.

Based off of observations, LPA observed Resident #1 (R1) urinal to not be clean and filled with residue.

Based on the evidence gathered during today’s investigation, the allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
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 4
Control Number 56-AS-20251204105800
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: 12/10/2025
NARRATIVE
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During today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099), LIC9099D were discussed and provided to Administrator Logan Harrison along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
12/04/2025 and conducted by Evaluator Raquel Hernandez
COMPLAINT CONTROL NUMBER: 56-AS-20251204105800

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: DATE:
12/10/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff does not change resident’s clothing/briefs.
INVESTIGATION FINDINGS:
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For the allegation, Staff does not change resident’s clothing/briefs.

LPA spoke with Resident #2 (R2) who indicated R1's clothing and briefs are kept clean. Additionally LPA observed laundry schedule for R1.

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

An exit interview was conducted and this report (LIC9099A) along with other reports were discussed and provided to Administrator Logan Harrison.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20251204105800
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee stated to replace R1's urinal with clean urinal. POC will be cleared.
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Based on observation, the licensee did not comply with section cited above by not ensuring R1's urinal was kept clean, which poses a potential health, safety, or personal rights risk to to 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: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4