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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191800633
Report Date: 12/27/2021
Date Signed: 12/27/2021 12:34:30 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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2021 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20211220101759
FACILITY NAME:ST JOHN OF GOD RESIDENCEFACILITY NUMBER:
191800633
ADMINISTRATOR:SABRINA TUCKERFACILITY TYPE:
740
ADDRESS:2468 SO. ST. ANDREWS PLACETELEPHONE:
(323) 731-0641
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY:40CENSUS: 75DATE:
12/27/2021
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Edgar GalangTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident sustained an injury while in care
Staff did not prevent resident from getting sick with pneumonia
Staff did not inform resident's authorized person in a timely manner of resident's injury
INVESTIGATION FINDINGS:
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On 12/27/21 Licensing Program Analysts (LPAS) Jade Jordan and Ngozi Nwaokori Conducted an Unannouced visit regarding the allegations above. LPA's were met by Administrator Edgar Galang, and the purpose of the visit was explained.

The Investigation consisted of the following: Physical Plant Tour, Interview conducted with Administrator, Record Review of Roster.

The investigation interview with administrator, and record review of rosters revealed that Resident mentioned in question for the above allegations does not reside at The Licensed Residential Care Facility For the Elderly (RCFE), over seen By Community Care Licensing Department (CCLD). LPA's confirmed that the resident listed in the narrative of the complaint resides, at the Skilled Nursing Facility " St. John of God" overseen by the Department of Public of Health.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
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 2
Control Number 11-AS-20211220101759
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ST JOHN OF GOD RESIDENCE
FACILITY NUMBER: 191800633
VISIT DATE: 12/27/2021
NARRATIVE
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 This agency has investigated the complaint alleging: "Resident sustained an injury while in care"
"Staff did not prevent resident from getting sick with pneumonia," "Staff did not inform resident's authorized person in a timely manner of resident's injury" 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.”

Exit Interview conducted and copy of this report was provided. No citations were issued during this visit.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2