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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 08/19/2021
Date Signed: 08/19/2021 12:54:32 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/04/2020 and conducted by Evaluator Christine Le
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200904114901
FACILITY NAME:ROSE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:TONY RIOSFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:63CENSUS: 55DATE:
08/19/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Morgan WilliamsTIME COMPLETED:
01:03 PM
ALLEGATION(S):
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Facility did not ensure resident was provided medications upon leaving facility.
Facility staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to investigate the above allegations. LPA met with Executive Director Morgan Williams.

LPA conducted interviews and reviewed facility files. The first allegation indicates that the facility did not ensure Resident 1 (R1) was provided medications upon leaving the facility. LPA was informed that on 6/29/20 R1 sustained a fall at the facility and was hospitalized due to hip pain. After the hospital, R1 was transferred to a SNF. The allegation indicates that the facility staff did not provide R1's medication list to the hospital and/or SNF. LPA reviewed the facility documentation and observed that the facility staff sent R1's medication list to the hospital and SNF. The second allegation indicates that the facility staff did not safeguard R1's personal belongings. LPA was informed that after R1's hospitalization and rehabilitation at the SNF, R1 and his/her family member decided to move the resident to another facility. LPA conducted interviews and was informed that R1's personal belongings were stored in the staff office until R1's family member could pick them up. LPA was informed that R1's responsible party picked up the belongings
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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 18-AS-20200904114901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
VISIT DATE: 08/19/2021
NARRATIVE
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near the end of 2020 or beginning of 2021. During the interviews, LPA could not determine if R1 was missing any personal items.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the Executive Director.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2