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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191591729
Report Date: 12/09/2020
Date Signed: 12/10/2020 03:45:00 PM



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
12/08/2020 and conducted by Evaluator Pat Rivas
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201208095143
FACILITY NAME:C.M.A.FACILITY NUMBER:
191591729
ADMINISTRATOR:AMARSINGHE, SWARNAFACILITY TYPE:
735
ADDRESS:18432 GRIDLEY RD.TELEPHONE:
(562) 860-2479
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY:46CENSUS: 46DATE:
12/09/2020
UNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Swarna Amarsinghe, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's blood is being drawn by unskilled professionals at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) P Rivas initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Swarna Amarsinghe, Administrator.
LPA Rivas conducted telephone interviews with the Administrator and four staff and Two residents between the hours of 2:00pm to 4:00pm. All staff and one resident indicated they have never drawn blood from R1 nor have they seen anyone draw blood from R1. R1 stated s/he did not want to be interviewed, "I don't want to talk about it." LPA was advised tht R1 does not have any conditions that would require the drawing of blood. Copy of R1's appraisal needs and services plan, physician's report and medication administration report faxed to LPA. LPA was unable to corroborate Allegation.
Based on LPAs interviews which were conducted record review(s), the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated.

A telephonic exit interview and appeal rights were conducted with Administrator Freeman, and a hard copy was provided via email for signature
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: (323) 213-1135
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
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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