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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221453
Report Date: 07/28/2022
Date Signed: 07/28/2022 12:12:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220727144348
FACILITY NAME:LUNDY FAMILY CARE HOMEFACILITY NUMBER:
191221453
ADMINISTRATOR:LUNDY, DWYANEFACILITY TYPE:
735
ADDRESS:964 SUMMITTELEPHONE:
(626) 794-5124
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:4CENSUS: 4DATE:
07/28/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff / Cynthia McNabb
Administrator / Dwayne Lundy		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff sat on resident and caused injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Cynthia McNabb and was later joined by the Administrator / Dwayne Lundy who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Staff sat on resident and caused injury."

During today's visit, LPA interviewed the Administrator, Quality Assurance Specialist (QAS) / Jenny Arellano from Frank D. Lanterman Regional Center (FDLRC), Staff 1 (S1) and Client 1 (C1).

The investigation revealed the following;
Allegation: Staff sat on resident and caused injury. The details of this allegation states that S1 sat on the leg of C1 and hurt her muscle.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the allegation. The date for the alleged incident is unknown. There were no witnesses to the alleged incident.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
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 28-AS-20220727144348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LUNDY FAMILY CARE HOME
FACILITY NUMBER: 191221453
VISIT DATE: 07/28/2022
NARRATIVE
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During the interview of C1, C1's statements were inconsistent as she initially stated the alleged incident happened on the sofa than she changed her statement and stated that the incident happened on the chair. C1 was unable to describe which room the alleged incident occurred. During the interview of S1, S1 denied sitting on the leg of C1 causing an injury. During today's visit, LPA observed C1 walking her usual self with no discomfort and no injuries to report. According to the QAS from FDLRC, an investigation was conducted by FDLRC and the allegation of "Staff sat on resident and caused injury" was found to be Unsubstantiated.
Based on interviews conducted and LPA's observation, there is insufficient evidence to support this allegation to be true.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2