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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 03/07/2022
Date Signed: 03/07/2022 11:36:19 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
10/13/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201013110332
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: 58DATE:
03/07/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Morgan WilliamsTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Neglect/Lack of care and supervision
Facility staff did not allow resident to transfer to a new facility
Facility staff charged resident for services not provided
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver finding for the above allegations. LPA Williams identified herself to Administrator, Morgan Williams, who was also informed of the purpose of the visit. The investigation consisted of records review and interviews with staff, witnesses, and residents.

On 7/3/2020, Resident #1 (R1) experienced an accidental fall. Department staff interviewed Staff #1 (S1) and Staff #2 (S2), who both stated that S2 was present as R1 experienced the fall. According to S1, S2 was in R1’s bedroom to pass out medications. S2 had asked R1 if R1 wanted to sit down, but R1 refused. S2 stated that as they were exiting R1’s bedroom, R1 tried to walk but tripped on their own feet. S2 stated that R1 fell down to the floor on R1’s right side in a seated position. S2 stated that they called for help from another caregiver to assist R1 back to bed. An assessment of R1 was conducted after R1 complained of hip pain. According to S1 and Staff #3 (S3), the consensus was to send R1 to the hospital. S3 stated that approximately 30 minutes had passed from first learning of the fall to the time R1 was sent to the hospital.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
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-20201013110332
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: 03/03/2022
NARRATIVE
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S1, S2, and S3 denied that neglect and/or lack of care and supervision resulted in R1’s fall. Furthermore, Department staff interviewed Social Worker #1 (SW1) who did not have any concerns of the facility regarding neglect or lack of care and/or supervision. Department staff have determined that the evidence collected Is not sufficient to substantiate the allegation of neglect and/or lack of care and supervision; therefore, the allegation is unsubstantiated.

In regards to allegation #2, Department staff interviewed R1’s son, who denied that the facility staff did not allow R1 to transfer to a new facility. According to R1’s son, they did not want R1 to go back to the facility after hospitalization due to the COVID-19 outbreak the facility was experiencing at that time. R1’s son stated that the facility staff did not prevent R1 from moving out of the facility. Department staff interviewed S1 who stated that the facility staff were informed by R1’s son that R1 would not be returning to the facility due to COVID-19 concerns. S1 stated that R1’s son initially expressed for R1 to return to the facility after hospitalization, but then changed their mind. R1 was relocated to another licensed care facility.

In regards to allegation #3, Department staff interviewed R1’s son who stated that they provided the facility a 30-day notice to remove R1 from the facility at the beginning of August 2020. A review of the facility’s admission agreement was conducted, in which it was revealed that the notice provided by R1’s son constituted as a 30-day notice where the facility is able to charge for the remaining 30 days. R1’s son then provided the facility a 5-day notice to remove R1 from the facility as they wanted to relocate R1 and their belongings immediately. Department staff interviewed S1, who stated that after receiving a 5-day notice from R1’s son, the facility staff would work with R1’s son on the remaining balance owed towards the facility. R1’s son stated that the facility and R1 reached a settlement agreement in September 2020 and paid for a set amount of which a portion was paid by the resident’s supplemental care agency. R1’s son stated that R1’s account is now settled appropriately.

Based on evidence obtained during the course of the investigation, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning that although the allegation 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 where this report (LIC 9099) was discussed and a copy was provided to the Administrator at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20201013110332
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
, CA 92507
FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
VISIT DATE: 03/07/2022
NARRATIVE
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S1, S2, and S3 denied that neglect and/or lack of care and supervision resulted in R1’s fall. Furthermore, Department staff interviewed Social Worker #1 (SW1) who did not have any concerns of the facility regarding neglect or lack of care and/or supervision. Department staff have determined that the evidence collected Is not sufficient to substantiate the allegation of neglect and/or lack of care and supervision; therefore, the allegation is unsubstantiated.

In regards to allegation #2, Department staff interviewed R1’s son, who denied that the facility staff did not allow R1 to transfer to a new facility. According to R1’s son, they did not want R1 to go back to the facility after hospitalization due to the COVID-19 outbreak the facility was experiencing at that time. R1’s son stated that the facility staff did not prevent R1 from moving out of the facility. Department staff interviewed S1 who stated that the facility staff were informed by R1’s son that R1 would not be returning to the facility due to COVID-19 concerns. S1 stated that R1’s son initially expressed for R1 to return to the facility after hospitalization, but then changed their mind. R1 was relocated to another licensed care facility.

In regards to allegation #3, Department staff interviewed R1’s son who stated that they provided the facility a 30-day notice to remove R1 from the facility at the beginning of August 2020. A review of the facility’s admission agreement was conducted, in which it was revealed that the notice provided by R1’s son constituted as a 30-day notice where the facility is able to charge for the remaining 30 days. R1’s son then provided the facility a 5-day notice to remove R1 from the facility as they wanted to relocate R1 and their belongings immediately. Department staff interviewed S1, who stated that after receiving a 5-day notice from R1’s son, the facility staff would work with R1’s son on the remaining balance owed towards the facility. R1’s son stated that the facility and R1 reached a settlement agreement in September 2020 and paid for a set amount of which a portion was paid by the resident’s supplemental care agency. R1’s son stated that R1’s account is now settled appropriately.

Based on evidence obtained during the course of the investigation, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning that although the allegation 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 where this report (LIC 9099) was discussed and a copy was provided to the Administrator at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2