191500496-11-20-2023-28-AS-FFIS-CY9RBA-20231206115221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500496
Report Date: 11/20/2023
Date Signed: 11/20/2023 03:14:33 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
11/16/2023 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231116170559

FACILITY NAME:	MOUNT SAN ANTONIO GARDENS		FACILITY NUMBER:	191500496
ADMINISTRATOR:	JOYCE FREMPONG		FACILITY TYPE:	741
ADDRESS:	900 EAST HARRISON AVENUE		TELEPHONE:	(909) 624-5061
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY:	520	CENSUS: 399	DATE:	11/20/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Joyce Frempong		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Facility is retaining a resident with a higher level of care needs.
Staff are not ensuring that resident is eating properly.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint investigation visit for the allegations above. LPA met with Administrator Joyce Frempong and the purpose of the visit was discussed.

On todays visit, LPA Villalobos toured the physical plant, interviewed staff #1-#6 (S1-S6) and residents #1-#10 (R1-R10). LPA reviewed and collected documents from R1's file, the food menu, and the staff and resident roster. The investigation revealed the following:

In regards to the allegation "Facility is retaining a resident with a higher level of care needs." it was alleged that R1 is not having their needs met by the facility as their clothes are not fitting and staff are not caring for R1....

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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 28-AS-20231116170559

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: MOUNT SAN ANTONIO GARDENS	FACILITY NUMBER: 191500496
	VISIT DATE: 11/20/2023

NARRATIVE

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(6) of (6) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews do not show that R1 required a higher level of care not being provided by the assisted living portion of the facility. As a continuing care retirement community, there is a skilled nursing portion for residents to move into when needed. According to interviews and file review, it has not been determined that R1 is in need of moving to that portion at the moment. R2 is the power of attorney of health care decisions for R1 and also stated that R1 is not in need of being moved to the skilled nursing portion. R2 is also R1's spouse and shares the same room. Interviews with R1 and R2 did not show that the staff are not meeting R1's needs or that clothes are not fitting. Based on interviews, files reviewed, and observations, there was not enough supportive evidence to concur with the reported allegation. 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.

In regards to the allegation "Staff are not ensuring that resident is eating properly" it was alleged that R1 is not eating properly in the facility. (6) of (6) Staff interviews denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews show that R1 is provided breakfast, lunch and dinner daily to their room. Interviews with staff also show that R1 is provided additional calorie dense drinks between meals. Interviews did show that R1 will at times not want to eat and will need reminders and encouragement. File review does show that the staff are to encourage R1 to eat their meals, are to cut up food for R1, and to provide between meal nourishment. Interviews with R2 stated that the facility staff are doing those things for R1. Staff interviews also stated that those things are being done for R1. LPA observed R1 receive in between meal nourishment as well as lunch during the time of this visit. Based on interviews, files reviewed, and observations, there was not enough supportive evidence to concur with the reported allegation. 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.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

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