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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191502342
Report Date: 01/30/2024
Date Signed: 01/30/2024 02:34:00 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/22/2024 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240122142232
FACILITY NAME:WESTERN ASSEMBLIES HOMEFACILITY NUMBER:
191502342
ADMINISTRATOR:LYNN HUGHESFACILITY TYPE:
740
ADDRESS:350 BERKELEY AVENUETELEPHONE:
(909) 626-3711
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:36CENSUS: 8DATE:
01/30/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lynn HughesTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff unlawfully removed a resident's medication
Staff are borrowing materials from other residents while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Lynn Hughes and explained the reason for the visit.

The Investigation consisted of the following: LPA conducted interviews with Administrator Lynn Hughes, Staff 1-2 (S1-2) and Residents 1-3 (R1-3). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-3's medications and Medication Administration Records (MARs) and collected copies of R1-3 MARs for December 2023 and January 2024. LPA additionally conducted a tour of the facility including supply storage room, medication room and observation of medication cart.


(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
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 3
Control Number 28-AS-20240122142232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WESTERN ASSEMBLIES HOME
FACILITY NUMBER: 191502342
VISIT DATE: 01/30/2024
NARRATIVE
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Investigation revealed the following: Regarding allegation, Staff unlawfully removed a resident's medication, it is alleged that a facility staff (administrator) has on more than one occasion put medications in their pocket to take home after a resident has passed away. Interview conducted with Administrator Lynn Hughes revealed that she has never taken any resident's medication out of the facility at any time. She stated that when a facility resident has passed away their medications are properly destroyed and are not taken out of the facility by anyone. Interviews conducted with facility staff revealed that facility staff have never unlawfully removed any resident's medication out of the facility. Staff stated that when a resident is no longer taking a certain medication or if a resident has passed away the facility will properly destroy the medication(s). Interviews conducted with 3 out of 3 residents revealed that they are satisfied with their medication management, they get their medications on time on a daily basis and they have never seen any staff take their medications out of the facility. LPA reviewed R1-3's MARs and observed that MARs were properly completed by facility staff after medication administration at the time of visit. LPA observed staff as they were administering medications to facility residents and did not observe anything of concern. LPA reviewed R1-3's Centrally Stored Medication and Destruction Records and observed the forms to be properly completed. LPA toured medication room and did not observe anything of concern. Based on interviews conducted with facility staff, facility residents, LPA review of records and observations, there was not enough supportive evidence to concur with the reported allegation.

For allegation, Staff are borrowing materials from other residents while in care, it is alleged that the facility does not have all the materials that are needed for each resident because supplies are not ordered timely and staff have to borrow materials from other residents. It is also alleged that there are residents that need extra care with lifting, dressing, hygiene care, assistance with feeding, assistance with wiping, diapering, and there are some residents that seem to have early onset dementia and don't have the capability of doing things independently who are not getting the assistance that they need at the facility due to the facility being short staffed. Interviews conducted with Administrator Lynn Hughes and S1-2 revealed that there are enough staff on schedule per shift to properly care for the residents in placement. They stated that there are 2-3 caregivers scheduled per shift along with other staff like housekeeping, cooks/ kitchen staff, activities, and maintenance. They stated that staff on schedule are able to meet the needs of all residents and provide the proper care that facility residents need which do include assistance with Activities of Daily Living (ADLs). Staff stated that there are always enough supplies available at the facility to meet the needs of
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240122142232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WESTERN ASSEMBLIES HOME
FACILITY NUMBER: 191502342
VISIT DATE: 01/30/2024
NARRATIVE
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the residents. They stated that supplies are ordered weekly and for the resident's that the families provide supplies, the administrator will contact the family when their supplies are running low and inform the family in a timely manner to ensure that the residents have their needed supplies in storage at the facility so that staff can meet their needs. Staff deny ever having to borrow materials from other residents and staff stated that they do not have any labor related concerns at the moment and indicated that they know who to contact if they ever do have any concerns. Interviews with 3 out of 3 residents revealed that the are satisfied with all the services that they receive at the facility, and staff assist them in a timely manner. They stated that the staff are always helpful and they do not have any concerns regarding there not being enough staff on schedule. They stated that they do not have any concerns regarding their materials, they always have the materials that they need and staff do not borrow any of their materials to use with other residents. During the visit, LPA inspected the storage closet and observed enough materials such as diapers, wipes and mattress pads to meet the needs of the resident's in placement. LPA observed some residents to have their incontinence materials in their rooms. LPA reviewed facility schedule and observed that there are enough staff on schedule to properly oversee and tend to residents daily needs, and facility daily operation. LPA observed enough staff on schedule during the visit. Based on interviews conducted with facility staff, facility residents, and LPA record review and observations, there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Administrator Lynn Hughes.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3