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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 06/21/2023
Date Signed: 06/21/2023 09:37:02 AM

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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2023 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20230602144800
FACILITY NAME:ROSE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:MORGAN E. WILLIAMSFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:63CENSUS: 58DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Morgan Williams- Administrator TIME COMPLETED:
09:35 AM
ALLEGATION(S):
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Staff handled resident in a rough manner causing bruising
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to deliver the findings for the allegation listed above. LPA met with Morgan Williams Administrator.

Interviews were conducted with 1 Client (C1), 1 Staff (S1), 2 Two outside parties (2 OP), documents were reviewed, and observations of Client #1. LPA observed bruises on (C1) arms and when asked what happened they said I banged them up. Records revealed that (C1) has behavior episodes and some medication(s) taken can contribute to bruising. The interviews with the (2 OP) and (S1) said that (C1) does have a history of behavior episodes that may cause harm to themselves and others.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
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-20230602144800
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: 06/21/2023
NARRATIVE
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Based on interviews, documents reviewed and observations, the above finding is Unsubstantiated. A finding of unsubstantiated means although the allegations 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 with Morgan Williams where this report was discussed and provided at the conclusion of the visit with the appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2