<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191501668
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:49:02 PM

Substantiated


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
09/14/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220914092736
FACILITY NAME:BRITISH HOME IN CALIFORNIA LTD, THEFACILITY NUMBER:
191501668
ADMINISTRATOR:MARLENE RAINENFACILITY TYPE:
741
ADDRESS:647 MANZANITA AVETELEPHONE:
(626) 355-7240
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY:41CENSUS: 34DATE:
09/15/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Staff / Rosario Munoz
Administrator / Marlene Rainen		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not inform responsible party of change in resident's condition.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 / Rosario Munoz and Administrator / Marlene Rainen
who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Facility did not inform responsible party of change in resident's condition."

During today's visit, LPA interviewed the Administrator and Staff 1 (S1). LPA made multiple attempts to speak with Staff 2 (S2) but was unsuccessful as phone calls were not returned. LPA was unable to interview Resident 1 (R1) as R1 is not at the facility and remains hospitalized at Huntington Memorial Hospital.
Also copies of the following documents were obtained and reviewed in reference to R1;

• In-house Incident/Unusual Occurrence Report • Emergency Information Sheet • Physician's Report
• Annual Assessment/Re-Appraisal of Needs & Services • UPDATED Unusual Incident/Injury Report dated 9/15/22 • Physician Note dated 9/8/22
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
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 5
Control Number 28-AS-20220914092736
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: BRITISH HOME IN CALIFORNIA LTD, THE
FACILITY NUMBER: 191501668
VISIT DATE: 09/15/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The investigation revealed the following;

Allegation: Facility did not inform responsible party of change in resident's condition. The details of this allegation states that the family of R1 was not notified after R1 sustained a fall on 9/8/22.
Based on interviews conducted, the statements obtained were consistent and corroborated with the allegation. Interviews conducted with staff and records reviewed confirmed that R1 sustained a fall on the morning of 9/8/22, at 5:30am. Facility staff failed to inform the family regarding the fall incident involving R1. Facility staff notified the family of R1 regarding a separate incident which occurred on 9/9/22, where R1 was transferred to Huntington Memorial Hospital, where she remains hospitalized. During today's visit, LPA obtained a copy of the UPDATED Unusual Incident/Injury Report dated 9/15/22, notifying CCL/Licensing of the fall incident (9/8/22) involving R1. Based on the investigation conducted, LPA found sufficient evidence to support this allegation to be true.

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220914092736
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: BRITISH HOME IN CALIFORNIA LTD, THE
FACILITY NUMBER: 191501668
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2022
Section Cited
CCR
87211(a)(1)
1
2
3
4
5
6
7
Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D). This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
1
2
3
4
5
6
7
Administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and submit a written plan detailing how facility will ensure that Reporting Requirements are followed as required according to the regulation. POC must be submitted to CCL by the POC due date.
8
9
10
11
12
13
14
This requirement is not being met as evidenced by:
Interviews conducted with staff and records reviewed confirmed that R1 sustained a fall on the morning of 9/8/22, at 5:30am. Facility staff failed to inform the family regarding the fall incident involving R1.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/14/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220914092736

FACILITY NAME:BRITISH HOME IN CALIFORNIA LTD, THEFACILITY NUMBER:
191501668
ADMINISTRATOR:MARLENE RAINENFACILITY TYPE:
741
ADDRESS:647 MANZANITA AVETELEPHONE:
(626) 355-7240
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY:41CENSUS: 34DATE:
09/15/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Staff / Rosario Munoz
Administrator / Marlene Rainen		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident did not receive medical attention as needed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 / Rosario Munoz and Administrator / Marlene Rainen
who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Resident did not receive medical attention as needed."

During today's visit, LPA interviewed the Administrator and Staff 1 (S1). LPA made multiple attempts to speak with Staff 2 (S2) but was unsuccessful as phone calls were not returned. LPA was unable to interview Resident 1 (R1) as R1 is not at the facility and remains hospitalized at Huntington Memorial Hospital.
Also copies of the following documents were obtained and reviewed in reference to R1;

• In-house Incident/Unusual Occurrence Report • Emergency Information Sheet • Physician's Report
• Annual Assessment/Re-Appraisal of Needs & Services • UPDATED Unusual Incident/Injury Report dated 9/15/22 • Physician Note dated 9/8/22
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220914092736
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: BRITISH HOME IN CALIFORNIA LTD, THE
FACILITY NUMBER: 191501668
VISIT DATE: 09/15/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The investigation revealed the following;

Allegation: Resident did not receive medical attention as needed. The details of this allegation states that R1 was not sent to the hospital after she sustained a fall.
Based on interviews conducted and records reviewed, the statements obtained were inconsistent and did not corroborate with the allegation. Staff interviewed denied not sending R1 to the hospital after R1 sustained a fall. R1 sustained a fall on the morning of 9/8/22, at 5:30am. R1 was seen by her Physician on 9/8/22, at 10am, at which time the Physician advised to keep an eye on R1 and if R1's symptoms worsen to take R1 to the ER. On 9/9/22, at 11:10am, facility staff observed a decline in R1 condition and transferred R1 to Huntington Memorial Hospital (E.R.), per Physician's instructions. Based on the investigation conducted, LPA found 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.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5