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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425610
Report Date: 03/28/2025
Date Signed: 03/28/2025 02:12:36 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
03/26/2025 and conducted by Evaluator Sarina Ramirez
COMPLAINT CONTROL NUMBER: 56-AS-20250326095909
FACILITY NAME:EXCELCAREFACILITY NUMBER:
366425610
ADMINISTRATOR:ANDERSON, DORRISFACILITY TYPE:
740
ADDRESS:11400 POPLAR STREETTELEPHONE:
(909) 796-4553
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:10CENSUS: 5DATE:
03/28/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Dorris AndersonTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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9
Staff did not store food properly
Staff does not ensure an adequate supply of food is maintained and accessible at the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met with Administrator Dorris Anderson, and discussed the purpose of the visit.

Regarding Allegation #1, LPA toured the facility and observed the main refrigerator in the kitchen had frosted over in the back of the refrigerator. LPA spoke with Administrator and LPA was informed the freezer is not properly working causing the frost. Administrator included the freezer drawer is being used as a refrigerator storing vegetables, while another freezer held all the frozen foods.

Regarding Allegation #2, LPA did not observe an adequate number of fruits and vegetables for residents in care. The strawberries in the refrigerator observed to be growing mold.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
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-20250326095909
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: EXCELCARE
FACILITY NUMBER: 366425610
VISIT DATE: 03/28/2025
NARRATIVE
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Based on the evidence gathered during the investigation, the above allegations are Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report LIC 9099, LIC 9099D was discussed, and a copy was provided, along with a copy of the appeal rights to Administrator Dorris Anderson.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Citations on this Visit Report are Under Appeal!

Control Number 56-AS-20250326095909
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: EXCELCARE
FACILITY NUMBER: 366425610
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
04/05/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee has agreed to repair or purchase new refrigerator, and submit proof to LPA by POC due date.
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Based on observation and interviews, the licensee did not ensure the facility to be in good repair at all times, which poses a potential Health, Safety, or Personal Rights risk 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: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Citations on this Visit Report are Under Appeal!

Control Number 56-AS-20250326095909
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: EXCELCARE
FACILITY NUMBER: 366425610
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
03/29/2025
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board... All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Licensee has agreed to purchase more fruits and vegetables and submit proof to LPA by POC due date.
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Based on observation and interviews, the licensee did not ensure the facility had an adequate food supply for residents in care, which poses an immediate Health, Safety, or Personal Rights risk 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: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4