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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 12/06/2023
Date Signed: 12/06/2023 02:32:23 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
11/28/2023 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20231128111534
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: 57DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Danica Turner TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident eloping from facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen an conducted an unannounced visit to initiate and deliver a complaint investigation for the allegation above. LPA Allen met with Danica Turner who was informed of the purpose of the visit.

The investigation consisted of observations, interviews with staff members and administrator Danica Turner who stated resident 1 (R1) was in the dining hall and last seen around 2:45 AM. Staff 1 (S1) noticed resident 1 (R1) was not in the dining area. S1 contacted the other two (2) staff members informing them that R1 was missing and requested that a tour of the facility be done inside and outside of the facility to locate R1. While touring the outside area at the main entrance (S1) noticed a free-standing wheelchair where the resident jumped over a fence. S1 canvased the neighborhood and R1 was found at Jack in the Box around 3:20AM where she was being interviewed by the police. S1 identified themselves and the facility that R1 eloped from and was escorted back to the facility. LPA observed unused wheelchairs located in a secure location of the facility inaccessible to residents in care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
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-20231128111534
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: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2023
Section Cited
CCR
87705(4)(A)
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Care of Persons with Dementia
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal..


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The Licensee has agreed to provide training on the cited regulation on CCR 87705(4)(A) and submit proof by fax of training with a statement of understanding signed by all staff by the POC date.
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This requirement is not met as evidenced by: Based on interviews & records review, it was found that R1 does have a history of leaving facilities unauthorized staff members did not ensure the saftey of the residents in care.Staff 1 found R1 30-45 minutes later outside of the facilty at Jack in the Box in the neighborhood. This pose immediate health, safety and personal rights risk to residents in care.
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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: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20231128111534
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: 12/06/2023
NARRATIVE
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The staff has been directed to do safety checks on R1 hourly and additional training will be conducted to ensure that the residents in care safety needs are met.

Based on LPA’s observations and interviews the preponderance of evidence standard has been met, therefore 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. A deficiency is being cited on the attached LIC 9099-D.

An exit interview was conducted, and this report was discussed and provided to Danica Turner at the conclusion of the visit with appeal rights.

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

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3