Complaint Investigation Report

360902129-5-22-2025-56-AS-KCLS-DJ5PTY-20250630113644

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SAN BERNARDINO , 1650 SPRUCE ST STE 200 MS29-27

This is an official report of an unannounced visit/investigation of a complaint received in our office on

07/26/2023 and conducted by Evaluator Magda Malcore

COMPLAINT CONTROL NUMBER: 56-AS-20230726133755

Facility staff left resident covered in feces

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Administrator, Melanie Niez, who was informed of today’s visit. The investigation consisted of LPA observations, pertinent record review and interviews with relevant parties.

Regarding the allegation, facility staff left resident covered in feces, interviews with staff and outside parties corroborate the allegation. On 7/24/23, R1 was observed to be in soiled diapers with feces on bedding and clothing. Staff assisted R1 with changing and bed cleaning. Interviews also reveal that the facility had been short staffed.

Based on this investigation, the above allegation is Substantiated. Substantiated meaning that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where reports (LIC9099&LIC9099-D) were discussed and provided with appeal rights to the Administrator at the conclusion of the visit.