191805041-6-23-2021-28-AS-RORN-CPRVR3-20230309153911

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191805041
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:07:43 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
05/10/2021 and conducted by Evaluator Christine Wong

COMPLAINT CONTROL NUMBER: 28-AS-20210510165909

FACILITY NAME:	GROOMES FAMILY HOME		FACILITY NUMBER:	191805041
ADMINISTRATOR:	ELIJAH HOPES		FACILITY TYPE:	735
ADDRESS:	235 WEST 107 STREET		TELEPHONE:	(323) 757-3325
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90003
CAPACITY:	6	CENSUS: 4	DATE:	06/23/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Phyllis Love		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility did not assist resident in getting a new ID

INVESTIGATION FINDINGS:

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On the above date, Licensing Program Analyst (LPA) Christine Wong conducted a subsquent visit to investigate above allegations. LPA met with administrator Phyllis Love and informed her the purpose of the visit.

The investigation consisted of the following: On 5/12/21, LPA Wong conducted the initial 10 days visit and a tour of the living room, dining area, kitchen, bathrooms and bedrooms. The kitchen had sufficient perishable and non-perishable food. Clients rooms and common areas were properly furnished. LPA did not observe any signs of neglect, abuse or other immediate health and safety threats. LPAs also interviewed two (2) staff. LPAs also obtained documents from Client#1 (C1) included face sheet, Medication record, recent physician report and the copy of the ID. On today's visit, LPA interviewed the adminsitrator and obtained bank statement for December 2020 and February 2020.

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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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Control Number 28-AS-20210510165909

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: GROOMES FAMILY HOME	FACILITY NUMBER: 191805041
	VISIT DATE: 06/23/2021

NARRATIVE

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The investigation consisted of the following: Allegation#1 "Facility did not assist resident in getting new ID." LPA reviewed Client#1 (C1) ID and it was expired on 01/20/2019 and administrator reported that she got a letter from Department of Motor Vehicles (DMV) and she attempted to reinstate the ID for C1 but afterward she did not follow up to get a new ID for C1 even the ID was expired.

Based on the record review and interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulation Title 22, Division 6, Chapter 1 are being cited on the attached LIC 9099D

An exit interview was conducted and a copy of this report was provided to the Administrator / Phyllis Love

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210510165909

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: GROOMES FAMILY HOME	FACILITY NUMBER: 191805041
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2021 Section Cited CCR 80070(a)	1 2 3 4 5 6 7	80070(a)Client records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. The requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility administrator will ensure all the clients record is current and adminsirator will send a letter stated that she will ensure all client record is current and send to LPA by POC due date
	8 9 10 11 12 13 14	Based on Record review, LPA reviewed Client#1(C1) ID was expired on 1/20/19 and administrator did not follow up or assist C1 in getting a new ID since then which posed a potiential risk a person 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: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC9099 (FAS) - (06/04)

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