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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 11/16/2023
Date Signed: 11/16/2023 02:58:57 PM

Substantiated


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
11/15/2023 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20231115085745
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:
11/16/2023
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Leilani Cortez Wellness DirectorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal items.
Staff did not communicate with authorized representative of resident's broken glasses.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA Allen met with Leilani Cortez Wellness Director who was informed of the purpose of the visit and allegations.

LPA Allen conducted interviews with staff members and outside parties who stated not all of resident 1's (R1) personal items were not provided upon discharge. During LPA visit there was one (1) personal item located. The interviews with staff members stated that R1 glasses were taped but they could not confirm or deny if the glasses were broken or if R1's authorized representative was notified. LPA did observe that glasses were broken and outside parites stated that R1's glasses were broken upon arrival.
Based on the evidence gathered during the investigation,the above allegation is found to be Substantiated.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are being cited on the attached LIC 9099-D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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 3
Control Number 56-AS-20231115085745
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: 11/16/2023
NARRATIVE
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An exit interview was conducted where this report was discussed and provided to Leilani Cortez Wellness Director at the conclusion of the visit with appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20231115085745
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2023
Section Cited
CCR
87218(a)
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(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. This requirement is not met as evidenced by:
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The licenssee has agreed to provide training to all staff members regarding the regulation and a signed statement of understanding signed by all staff members by the POC date of 11/23/2023
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The licensee did not ensure that R1's personal belongings were returned to their responsible party upon their dischage from the facility and 1 item was located during LPA's visit.
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Type B
11/23/2023
Section Cited
CCR
87211(1)
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A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.....This requirement is not met as evidenced by:
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The licenssee has agreed to provide training to all staff members regarding the regulation and a statement of understanding signed by all staff members by the POC date of 11/23/2023
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The licensee did not report to R1's responsible party or ccl of R1's broken eye glases that are required
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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: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3