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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880919
Report Date: 08/05/2026
Date Signed: 08/05/2026 04:49:26 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
11/18/2025 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 56-AS-20251118122519
FACILITY NAME:LOVE 2 CARE HOMESFACILITY NUMBER:
361880919
ADMINISTRATOR:JACKSON, TERRIFACILITY TYPE:
740
ADDRESS:19432 US HIGHWAY 18TELEPHONE:
(760) 297-6277
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:6CENSUS: 5DATE:
08/05/2026
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jasmine Goudeau, CaregiverTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff neglect resulted in a resident's death
Staff neglect resulted in a resident sustaining a pressure injury
Staff did not meet a resident's catheter needs
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Becky Mann and Lavette Farlow conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Jasmine Goudeau, Caregiver and explained the purpose of the visit. The investigation consisted of LPA pertinent record reviews, observations and interviews with staff and residents.

On 11/18/2025, the Department received a complaint with the allegation of Neglect/Lack of Care and Supervision – Staff neglect resulted in a resident's death. The Department investigation consisted of review of facility and medical records, observations, and interviews with pertinent individuals. Records obtained did not support staff neglect occurred. Resident #1 (R1) medical diagnoses included organ failures, dehydration, and severe UTI. Hospital records further revealed that R1 was admitted to the hospital due to decreased responsiveness/lethargy for 1 to 2 days. The Certificate of Death indicated that R1’s cause of death was septic shock due to acute encephalopathy, an acute left cerebellar stroke, and metastatic breast cancer. The allegation of Staff neglect resulted in a resident's death is unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
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 4
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
11/18/2025 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 56-AS-20251118122519

FACILITY NAME:LOVE 2 CARE HOMESFACILITY NUMBER:
361880919
ADMINISTRATOR:JACKSON, TERRIFACILITY TYPE:
740
ADDRESS:19432 US HIGHWAY 18TELEPHONE:
(760) 297-6277
CITY:APPLE VALLEYSTATE:CAZIP CODE:
92307
CAPACITY:6CENSUS: 5DATE:
08/05/2026
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jasmine Goudeau, CaregiverTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Staff mishandled a resident's medications
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Becky Mann and Lavette Farlow conducted an unannounced visit to the facility to initiate a complaint investigation. LPA Mann met with Eula Jones, Caregiver and explained the purpose of today's visit. The investigation consisted of LPA observations, pertinent document reviews, and interviews with staff and residents.

The allegation that Staff mishandled a resident's medications. LPA reviewed 2 residents medication. Based on LPA observations and record reviews the MAR (Medication Administration Record) it did not match the bubble packs. The medications were administered to the residents and the MAR was not marked.

Based on LPA observations, interviews and records review, the above allegation is Substantiated. A determination that the complaint is substantiated means that the allegation is/are valid because the preponderance of the evidence standard has been met.
An exit interview was conducted where this report was discussed and provided to Jasmine Goudeau, Caregiver.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20251118122519
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: LOVE 2 CARE HOMES
FACILITY NUMBER: 361880919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2026
Section Cited
HSC
87465(e)
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87465 (e)For every prescription and nonprescription PRN medication which licensee provides assistance shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, a label on the medication.
Requirement was not met:
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Administrator will train staff on how to use MAR (Medication Administration Record) to document medications being administered. Administrator will submit proof to LPA by Plan of Correction (POC) due date
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Based LPA observations and record reviews, Medication Administration Record (MAR) did not match bubble packs. The MAR was not marked when staff administered medication to residents, which poses immediate health, safety to persons 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.
SUPERVISOR'S NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20251118122519
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: LOVE 2 CARE HOMES
FACILITY NUMBER: 361880919
VISIT DATE: 08/05/2026
NARRATIVE
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The allegation that Staff neglect resulted in a resident sustaining a pressure injury. Interviews with Resident #2(R2) and Resident #3 (R3) revealed that they have not had pressure injuries while at the facility. Interviews with 3 staff stated that residents have not sustain pressure injuries while at the facility.

The allegation that Staff did not meet resident’s catheter needs. Interview with witness revealed uncertainty about whether R1 had a catheter. The Department obtained and reviewed R1’s medical records which did not indicate prior use of a catheter on R1. Interviews with Staff #1 (S1), (S2), and (S3) revealed that R1 did not use a catheter throughout the stay at the facility. The hospital record revealed on 08/12/2025, at 1150 hours, while at the hospital, that a urethral catheter was placed. It was reported that the necessity was for critically ill patients requiring hourly urine output measure for clinical decision. Based on interviews with staff and records obtained, there’s insufficient evidence to prove that facility staff did not meet resident’s catheter needs, therefore, the allegation unsubstantiated.

Based on evidence obtained during this investigation, the allegation above is Unsubstantiated. A finding of unsubstantiated means there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Jasmine Goudeau, Caregiver at the conclusion of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4