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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 10/30/2023
Date Signed: 12/15/2023 04:47:21 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2023 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20230912084226
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: 56DATE:
10/30/2023
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Leilani Cortez-LVNTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not meet resident's hygiene needs while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the allegation above. LPA Allen met with Leilani Cortez-LVN who was informed of the purpose of the visit.

On10/30/2023 LPA observed Resident 1's (R1) room to be clean and free of odors. LPA also observed R1's bed linen to be clean, free of stains and orders. LPA observed documentation that reflects there is a schedule in place for R1’s weekly hygiene needs or as needed to be met.
The interviews with the staff members stated that the residents have schedule for showers twice a week or as needed daily. LPA attempted to have a conversation with R1, but they were not willing to communicate during the visit however LPA did observe R1’s hygiene need seemed to be met, R1’s hands/nails were free of debris, clean clothing free of stains and odors.

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

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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-20230912084226
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: 10/30/2023
NARRATIVE
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Based on LPA’s observations, interviews, and documents reviewed the allegation as to staff did not meet the resident’s hygiene needs are Unsubstantiated

An exit interview where this report was discussed, and a copy was provided to Leilani Cortez-LVN at the conclusion of the visit with appeal rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2