191800633-8-20-2021-11-AS-MCAA-C7ZQYE-20211021123500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191800633
Report Date: 03/30/2021
Date Signed: 08/20/2021 10:09:12 AM

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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20210326113304

FACILITY NAME:	ST JOHN OF GOD RESIDENCE		FACILITY NUMBER:	191800633
ADMINISTRATOR:	SABRINA TUCKER		FACILITY TYPE:	740
ADDRESS:	2468 SO. ST. ANDREWS PLACE		TELEPHONE:	(323) 731-0641
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90018
CAPACITY:	40	CENSUS: 12	DATE:	03/30/2021
		UNANNOUNCED	TIME BEGAN:	11:47 AM
MET WITH:	Alma Amonzon Patient Care Coordinator		TIME COMPLETED:	11:48 AM

ALLEGATION(S):

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Resident sustained a fracture while in care

INVESTIGATION FINDINGS:

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**This is an Ameded document to reflect the change in allegation listed as personal rights, to Resident sustained a fracture in care. All information remains the same** 03/30/21 Licensing Program Analyst LPA/ Jade Jordan initiated a Subsequent 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 subsequent complaint investigation was conducted telephonically with Alma Amonzon, the facility Patient Care Coordinator.
Investigation consisted of the following: Obtained facility staff roster, Resident Roster, Special Incident Reports interviews conducted with (1) staff, virtual tour, and view of residents in care.
It was determined, after Record Review, that named individual, does not reside in A Licensed Community Care facility, over seen By the Community Care Licensing Department State of California.
Based on the information given this agency has investigated the complaint alleging Personal Rights. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
An exit interview was conducted, and a copy of this report was given. No citations were issued. Advised to sign and return to LPA via email at Jade.Jordan@dss.ca.gov, or Fax 323-981-1781

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

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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