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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425610
Report Date: 12/29/2025
Date Signed: 12/29/2025 02:43:23 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
12/08/2025 and conducted by Evaluator Sarina Ramirez
COMPLAINT CONTROL NUMBER: 56-AS-20251208093045
FACILITY NAME:EXCELCAREFACILITY NUMBER:
366425610
ADMINISTRATOR:ANDERSON, DORRISFACILITY TYPE:
740
ADDRESS:11400 POPLAR STREETTELEPHONE:
(909) 796-4553
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:10CENSUS: 5DATE:
12/29/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator Dorris AndersonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing residents food of good quality.
Staff do not provide resident with a variety of food.
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to deliver findings on the allegations mentioned above. LPA met with Administrator Dorris Anderson and explained the purpose of the visit.

Regarding allegation #1, LPA observed the resident’s meal during lunch and it appeared to be of good quality.

LPA interviewed 5 residents, 4 of the 5 residents informed LPA the food being provided is of good quality. 1 of the 5 residents was unable to answer LPA’s question.

LPA interviewed two (2) staff both informed LPA the residents are being provided with good quality food every day. Administrator informs LPA they follow the food plan from Loma Linda University to help maintain their good health.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
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 2
Control Number 56-AS-20251208093045
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: EXCELCARE
FACILITY NUMBER: 366425610
VISIT DATE: 12/29/2025
NARRATIVE
1
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3
4
5
6
7
8
9
10
11
12
13
14
15
16
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18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding allegation #2, LPA observed the facility menu and toured the facility kitchen, LPA observed the facility to have different variety options for residents.

LPA interviewed 5 residents, 2 of the 5 residents were unable to answer LPA’s question. 3 of the 5 residents informed LPA they are provided with variety options.

LPA interviewed two (2) staff, both staff informed LPA the residents are provided with a variety of food options. Administrator explains to LPA the residents are accommodated and the menu is changed upon request.

Regarding allegation #3, LPA interviewed 5 residents. 2 residents were unable to answer LPA’s question. 3 of the 5 residents informed LPA their belongings are kept safe in their rooms.

LPA interviewed caregiver on duty and informed LPA no residents’ belongings have been stolen at the facility. Administrator explains to LPA it is alleged resident #6 (R6) had stolen an item from resident #7 (R7)'s room, however it was retrieved, given back to the resident, and R7 was given a key to lock their room to ensure no other items would be stolen.

Based on LPA’s observations, staff and resident interviews, and relevant documentation, the allegations are determined to be Unsubstantiated. An Unsubstantiated finding means that although the allegations may be valid or could have occurred, there is insufficient evidence to support that the alleged violations did or did not happen.

An exit interview was conducted with Caregiver Rose Viernes, 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: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2