366425610-6-19-2026-56-AS-KCLS-DVEMKR-20260626094112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425610
Report Date: 06/19/2026
Date Signed: 06/19/2026 02:48:09 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
03/24/2025 and conducted by Evaluator Sarina Ramirez

COMPLAINT CONTROL NUMBER: 56-AS-20250324114757

FACILITY NAME:	EXCELCARE		FACILITY NUMBER:	366425610
ADMINISTRATOR:	ANDERSON, DORRIS		FACILITY TYPE:	740
ADDRESS:	11400 POPLAR STREET		TELEPHONE:	(909) 796-4553
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	10	CENSUS: 4	DATE:	06/19/2026
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Caregiver Rose Viernes		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff neglect resulted in a resident sustaining pressure injuries while in care
Staff did not ensure a resident consumed an appropriate amount of liquid while in care
Resident sustained unexplained injuries while in care
Staff allowed a resident to be soiled while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on a complaint investigation regarding the above allegations. LPA met with Caregiver Rose Viernes and discussed the purpose of the visit.

Regarding Allegation #1: It was alleged that Resident #1 (R1) developed a pressure injury while in care due to staff neglect. LPA was unable to interview R1, as they are no longer a resident of the facility. LPA interviewed two (2) staff members. One (1) staff member reported that, to their knowledge, R1 did not have any pressure injuries. The second staff member stated that R1 had a small stage 2 wound on the buttocks; however, they did not believe it was the result of neglect. The Administrator reported suspecting that R1 may have had cancer and stated the concern was communicated to InnovAge.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

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-20250324114757

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: 06/19/2026

NARRATIVE

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Regarding Allegation #2: LPA observed a cup of water in each resident’s bedroom. LPA interviewed two staff members, both of whom stated they ensure residents remain adequately hydrated. The Administrator reported that water is always available in residents’ rooms. Both staff members also explained that although R1 consistently had water available, R1’s health was declining, and they were experiencing difficulty swallowing. This concern was communicated to InnovAge; however, no additional follow-up was reportedly conducted. LPA interviewed five (5) residents, all of whom reported receiving an adequate amount of liquids.

Regarding Allegation #3: It was alleged that R1 sustained unexplained injuries while in care. LPA interviewed two (2) staff members, both of whom stated that R1 did not sustain any falls at the facility during the period in question. They reported being informed that R1 had slipped out of their wheelchair while at InnovAge. One (1) staff member observed bruising on R1’s buttocks, and R1 reported the injury occurred due to slipping at InnovAge. The Administrator stated that Resident #2 (R2) reported witnessing R1 slip out of their wheelchair at InnovAge; however, R2 was unable to be interviewed as they were out in the community.

Regarding Allegation #4: LPA interviewed two (2) staff members, both of whom stated that R1 was never left soiled, nor are other residents left soiled while in care. LPA interviewed one (1) resident, who reported that staff do not leave them soiled and that when assistance is needed, staff respond promptly.

Based on LPAs observations, record review, and interviews, the above allegations are Unsubstantiated; meaning 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 where this report was discussed and a copy was provided to Caregiver Rose Viernes at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC9099 (FAS) - (06/04)

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