191501668-9-7-2022-28-AS-MVAO-CKJSPY-20221025140352

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191501668
Report Date: 09/07/2022
Date Signed: 09/07/2022 12:03:20 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
05/03/2021 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210503103907

FACILITY NAME:	BRITISH HOME IN CALIFORNIA LTD, THE		FACILITY NUMBER:	191501668
ADMINISTRATOR:	MARLENE RAINEN		FACILITY TYPE:	741
ADDRESS:	647 MANZANITA AVE		TELEPHONE:	(626) 355-7240
CITY:	SIERRA MADRE	STATE: CA	ZIP CODE:	91024
CAPACITY:	41	CENSUS:	DATE:	09/07/2022
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Executive Director, Marlene Rainen		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff member did not allow residents access to Ombudsman services.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint investigation and deliver findings for the allegation listed above. Upon arrival, LPA met with Executive Director, Marlene Rainen and explained the purpose of today’s visit.
During the initial visit conducted telephonically (due to Covid-19) on 5/06/22, LPA Elizabeth Irra requested the Administrator (via email) to provide the following documents:
• Staff Roster (with contact phone numbers)
• Resident Roster (with contact phone numbers)
• Visitors Policy for March 2021 to current
• Visitors log/sign-in sheet(s) for March 2021 to current
• Staff schedule for March 2021 to current

During today’s visit, LPA Pena interviewed the following: Two (2) Staff, Staff #1 (S1), Staff #2 (S2), (1) Witness, Witness #1 (W1), the Executive Director/Administrator (A1) and obtained a copy of the Visitor's log for March 2021.

Continued on LIC 9099-C……………..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

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-20210503103907

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: 09/07/2022

NARRATIVE

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In regard to the allegation: Staff member did not allow residents access to Ombudsman services. It was alleged that on 3/09/2021, Ombudsman (OMB) was stopped by A1, who would not allow the OMB to enter the facility to check in with residents. A1 indicated the OMB can only meet with residents if they happen to come out of their rooms.

On 5/06/2021 and 5/07/2021, the Executive Director, Marlene Rainen (A1) stated (via email) that she never prevented OMB from seeing the residents in their campus and only asked her to follow their Covid policy and protocols. A1 claimed that OMB did not sign-in when requested to do so and did not present any identification to the staff, not even a business card. A1 stated that the facility did not allow any family or strangers into buildings due to their Covid protocols.

LPA's interview with A1 today confirmed that she did not allow anyone, including medical personnel, ombudspersons, local health personnel, etc. to go inside the residents cottages. A1 stated she allowed outside visit only after following covid protocols and that applied to everyone.

LPA's interview with S1 revealed that the facility was very strict with visitors around that time due to Covid-19 pandemic. She could not recall if the OMB was not allowed entry to see residents but S1 stated that A1 was only protecting the vulnerable residents. S2 stated that she recalled that OMB was asked to go around the facility but could not go inside the cottages until after seeing A1. Interview with W1 stated that he was not aware that A1 or the facility was not allowing visitors entry. When he visited, he was allowed to visit outdoors only, and had to make a reservation and follow covid screenings.

Based on LPAs’ interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Marlene A. Rainen. Copy of the Reports and Appeal Rights given.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210503103907

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: 09/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/21/2022 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities....(a) Residents...shall have all of the following personal rights:(11)To have their visitors, including ombudspersons..permitted to visit privately...without prior notice,..provided that the rights of other residents are not infringed upon.	1 2 3 4 5 6 7	Administrator will review plan of operation and abide by the visitation regulation, that allows all essential workers to visit at any time unannounced. Administrator will provide in-service training to staff on visitation and provide a copy to LPA by POC due date.
	8 9 10 11 12 13 14	The requirement is not met as evidenced by: On 3/09/2021, Administrator refused OMB to visit and check-in with residents. OMBs are essential visitors and should have not been refused entry.This possess a potential health and safety risk to residents in care.	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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC9099 (FAS) - (06/04)

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