366426422-1-30-2026-56-AS-KCLS-DR2UUG-20260206145330

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 01/30/2026
Date Signed: 01/30/2026 10:40:06 AM

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
03/22/2024 and conducted by Evaluator Sarina Ramirez

COMPLAINT CONTROL NUMBER: 56-AS-20240322114507

FACILITY NAME:	ROSE GARDEN RESIDENTIAL CARE		FACILITY NUMBER:	366426422
ADMINISTRATOR:	DANICA TURNER		FACILITY TYPE:	740
ADDRESS:	1350 WABASH AVE.		TELEPHONE:	(909) 794-1040
CITY:	MENTONE	STATE: CA	ZIP CODE:	92359
CAPACITY:	63	CENSUS: 53	DATE:	01/30/2026
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Executive Director Melissa Buckridge		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Questionable death
Staff did not assist resident with incontinence care
Resident sustained bruises while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to deliver findings on the allegation mentioned. LPA met with Executive Director Melissa Buckridge and explained the purpose of the visit. The Department's investigation involved interviews and records review.

Regarding allegation #1, Department staff conducted an investigation which revealed. On the evening of 02/18/2024, resident #1 (R1) was found on the floor in their room by facility staff, positioned near the bed. It was presumed R1 fell from the bed. When asked by staff, R1 was unable to explain what happened but stated to be ok. Staff observed a golf ball-sized bump on R1’s forehead and immediately called 911. R1 was transported to the hospital emergency room, where diagnostic imaging revealed multiple injuries, including a closed fracture of multiple ribs on the left side, a displaced fracture of the right clavicle, and a subdural hematoma. R1 remained hospitalized and passed away on 02/27/2024. Interviews with facility staff and outside parties confirmed that R1 had no prior falls at the facility and there were no reports or documentation of R1 being dropped during transfers.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240322114507

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: 01/30/2026

NARRATIVE

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Department staff were provided with documentation of care and supervision consistent with R1’s needs. Based on the investigation, there is no evidence that R1’s death resulted from neglect or lack of care and supervision by facility staff.

Regarding allegation #2, LPA conducted interviews with residents and staff. Interviews were conducted with six (6) residents. Two (2) residents reported they do not require assistance with incontinence care. Two (2) residents stated that staff provide incontinence care assistance in a timely manner. One (1) resident was unable to confirm whether staff assist with incontinence care. Interviews with two (2) staff members indicated that they assist residents with incontinence care promptly. One (1) staff member noted that residents requiring incontinence care assistance are typically non-verbal.

Allegation #3, Resident sustained bruises while in care. It was reported that R1 was observed with a bruise on the arm believed to resemble a handprint. Photos of the bruise were observed by Department staff. The images did not appear to show a hand shaped mark. It was reported that staff in the facility caused the bruise grabbing R1’s arm and later throwing R1 on the bed. Interviews with facility staff and other residents did not reveal any evidence or witness to corroborate physical abuse by facility staff. Based on the investigation, there is no evidence to support the allegation of physical abuse.

Based on the information gathered, the allegations were determined to be UNSUBSTANTIATED. An Unsubstantiated complaint means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Executive Director Melissa Buckridge and a copy of this report was provided at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026

LIC9099 (FAS) - (06/04)

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