<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 03/26/2024
Date Signed: 03/26/2024 12:04:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
04/29/2022 and conducted by Evaluator Anna Fannell
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220429162510
FACILITY NAME:ROSE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:63CENSUS: 55DATE:
03/26/2024
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Ginnie Loekner - Executive DirectorTIME COMPLETED:
12:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable death
Lack of supervision resulting in resident falling

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent visit to deliver findings for the above allegations. LPA met with Executive Director (ED) Ginnie Loekner who was informed of the reason for the visit. LPA Bueno conducted the initial investigation, staff and witness interviews, and records review.

Allegation 1: Questionable death. On 1/31/22, the Department received two incident reports on R1 with both incident dates of 1/28/22. The first incident report stated that R1 was found on the sidewalk outside of the dining hall in an apparent fall with bleeding on the right side of their forehead and the second incident reported that R1 was in the local hospital and needed surgery. Staff statements revealed that R1 was found on the ground without any assistive device or any other resident or staff. Documents from emergency medical transport (EMT) state that R1 met the responding crew and with Fire medic. EMT records further state that R1 was monitored with an ECG and continually observed with no changes, no complaints, and no bleeding or shortness of breath, and no nausea. Witness interview confirmed that R1 remained in the hospital from 1/28/22 until their death on 2/9/22. Witness further stated that R1 required emergency brain surgery on 1/28/22 and subsequently suffered
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
04/29/2022 and conducted by Evaluator Anna Fannell
COMPLAINT CONTROL NUMBER: 56-AS-20220429162510

FACILITY NAME:ROSE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:63CENSUS: 55DATE:
03/26/2024
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:TIME COMPLETED:
12:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard resident's personal items.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Anna Fannell conducted a subsequent visit to deliver findings for the above allegations. LPA met with Executive Director (ED) Ginnie Loekner who was informed of the reason for the visit. LPA Bueno conducted the initial investigation, staff and witness interviews, and records review.

The allegation is Staff did not safeguard resident's personal items. Witness interview revealed that R1 was missing a bible, a cross, and an antenna. Witness stated that they were able to locate R1’s bible and cross within R1's packed up belongings but the antenna was still missing. Interviews with staff revealed that all of the items in R1’s room was packed and staff could not locate R1’s missing antenna. Furthermore, staff do not recall if R1 still had their antenna when their belongings were packed or if the antenna had been disposed of any time before R1 left the property. Review of R1's LIC621 Client/Resident Personal Property And Valuables lists an antenna as part of R1's belongings when they moved in to this facility. This allegation is therefore SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 56-AS-20220429162510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
VISIT DATE: 03/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A finding that the complaint is SUBSTANTIATED means that the allegations are valid as the preponderance of the evidence standard has been met. Refer to LIC809-D for deficiency cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Administrator Loekner.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 56-AS-20220429162510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2024
Section Cited
CCR
87217(j)
1
2
3
4
5
6
7
87217 Safeguards for Resident Cash, Personal Property, and Valuables
(j) Upon the death of a resident, all cash resources, personal property, and valuables of that resident shall immediately be safeguarded.
1
2
3
4
5
6
7
Licensee agrees to review the regulation cited for safeguard of resident cash, property, and valuables. Licensee shall submit statement of understanding of regulations reviewed by end of POC due date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Based on records reviewed and interviews conducted, neither staff nor R1's representative were able ro locate R1’s missing antenna.This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 56-AS-20220429162510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
VISIT DATE: 03/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
from cardiovascular complications following the surgery. This allegation is therefore unsubstantiated.

Allegation 2: Lack of supervision resulting in resident falling. The Department received two incident reports involving R1 on 1/28/22. LPA Fannell reviewed LIC 602 Physician’s report signed on 08/18/21 stating that R1 uses glasses, had no motor impairment or paralysis, and does not use any walking assistive device. LPA reviewed pre-placement appraisal form, LIC 603, completed by family member states that R1 is not able to walk without any physical assistance and R1 will sometimes use a walker but, yes is able to walk with a cane. LPA could not find corroborating evidence that R1 requires assistance or supervision while walking. This complaint is unsubstantiated.

Based on the investigation, the above findings are 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 where a copy of the entirety report was provided to Administrator Loekner at the conclusion of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
04/29/2022 and conducted by Evaluator Anna Fannell
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220429162510

FACILITY NAME:ROSE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:63CENSUS: 55DATE:
03/26/2024
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Ginnie Loekner - Executive DirectorTIME COMPLETED:
12:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility overcharged authorized representative
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Anna Fannell conducted a subsequent visit to deliver findings for the above allegation. LPA met with Executive Director (ED) Ginnie Loekner who was informed of the reason for the visit. LPA Bueno conducted the initial investigation, staff and witness interviews, and records review.

The allegation is Facility overcharged authorized representative. Records reviewed show that R1 moved into this facility on 9/1/21 and was a participant of California Program of All-Inclusive Care for the Elderly (PACE) from 09/1/21 through 12/31/21 with a rental co-payment of $1153. Records confirmed that R1’s September 2021 payment was recorded on 9/22/21 and a recurring payment authorization form was signed on 10/14/21 specifying R1’s co-pay of $1153. Furthermore, records revealed that R1’s rent was paid timely from October through November 2021. Staff interview revealed that the business office staff separated from the facility in December 2021 and R1’s rent was not processed in December 2021. LPA was not provided with any records showing that R1’s January 2022 rent was paid, and the facility has no record that January 2022 was paid. The facility could not process any new payments as the authorization form was only valid till December 2021. LPA
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 56-AS-20220429162510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROSE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 366426422
VISIT DATE: 03/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
reviewed records showing that the facility kept record of payments made by R1’s authorized party and the payment for December 2021 was processed in February 2022. Records show that January 2022 rent has not been paid as of 3/15/2023. This allegation is therefore UNFOUNDED.

The Department has found that the allegation is UNFOUNDED meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was provided to Administrator Loekner.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7