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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426422
Report Date: 03/30/2026
Date Signed: 03/30/2026 11:12:04 AM

Substantiated


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
09/11/2025 and conducted by Evaluator Edith Conchas
COMPLAINT CONTROL NUMBER: 56-AS-20250911124320
FACILITY NAME:ROSE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
366426422
ADMINISTRATOR:SCHAMONE BARDFACILITY TYPE:
740
ADDRESS:1350 WABASH AVE.TELEPHONE:
(909) 794-1040
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:63CENSUS: DATE:
03/30/2026
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Melissa Buckridge, Administrator TIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff chemically restrained resident
INVESTIGATION FINDINGS:
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On 3/30/2026, Licensing Program Analyst (LPA) Edith Conchas conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Melissa Buckridge and explained the purpose of the visit.

Staff chemically restrained resident

The investigation consisted of interviews with staff and review of pertinent documents. LPA reviewed S7 file and observed a final disciplinary warning document dated 9/25/2025, which states S7 was in misconduct by using or possessing drugs on company premises and a medication error. In addition, LPA observed that on 9/25/2025 S7 was terminated from employment due to staff reporting observing S7 with cannabis in personal possession.

Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
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-20250911124320
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: 03/30/2026
NARRATIVE
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LPA conducted five (5) staff interviews and interviews revealed that S7 no longer works at the facility. Interview with S4 revealed that S7 disclosed to S4 giving a THC drink to R1. S4 and S5 stated they observed R1 appearing “out of it” shortly after S7 reported providing the THC drink. LPA was unable to interview R1, R1 passed on 11/15/2025.

Based on LPA’s observations, record review, and interviews that were conducted, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 are being cited on the attached LIC 9099-D.

An exit interview was conducted, and a copy of this report was provided to the Facility Administrator, Melissa Buckridge.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250911124320
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: 03/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2026
Section Cited
HSC
1569.625(c)(7)
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(7) Dementia care, including the use and misuse of antipsychotics, the interaction of drugs commonly used by the elderly, and the adverse effects of psychotropic drugs for use in controlling the behavior of persons with dementia. This requirement is not met as evidenced by:
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Staff 7 was terminated on 9/25/2025. Administrator will conduct a staff training on Health and safety regulation 1569.625(c) (7) Adminsitrator will provide a copy of the training topic and sign in sheet upon completion to LPA via email on or by 4/08/2026.
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Based on LPA's record review and interviews, staff 7 was observed having and using canabis susbtance while working at facility which poses an immediate health and safety 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: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3