197602143-6-4-2023-31-AS-NMAN-CUGVA4-20230807161518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602143
Report Date: 06/04/2023
Date Signed: 06/04/2023 05:25:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230417130206

FACILITY NAME:	HOME SWEET HOME II		FACILITY NUMBER:	197602143
ADMINISTRATOR:	ALFONSO DE LA CUESTA		FACILITY TYPE:	740
ADDRESS:	23788 VIA JACARA		TELEPHONE:	(661) 254-3336
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 3	DATE:	06/04/2023
		UNANNOUNCED	TIME BEGAN:	11:02 AM
MET WITH:	Alex Ignacio		TIME COMPLETED:	05:33 PM

ALLEGATION(S):

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Resident sustained unexplained injury while in care
Staff did not provide proper supervision to resident in care
Staff did not provide proper medication assistance to resident in care
Staff did not provide proper transfer assistance to resident in care
Staff do not provide proper food service to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Alex Ignacio and explained the reason for the visit. The administrator, Alfonso De La Cuesta, designated Alex Ignacio as the responsible person to sign and accept this report.

---Resident sustained unexplained injury while in care

It was alleged that sustained a deep laceration to calf while in care. To investigate the allegation, on 04/25/2023, requested documents at 10:30 AM and interviewed (04) four staff between 11:30 AM to 02:00 PM. Record review shows that the resident sustained a skin tear (skin avulsion) of the top layer of skin and has edema. During interviews with staff, all staff stated they did not witness the injury to Resident #1 (R1).

(CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2023

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 31-AS-20230417130206

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOME SWEET HOME II	FACILITY NUMBER: 197602143
	VISIT DATE: 06/04/2023

NARRATIVE

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All staff stated that R1 is combative, often kicks to sit up and suspect that R1 hit their leg against their wheelchair.

Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Staff did not provide proper supervision to resident in care

It was alleged that staff leave resident in their room and failing to check on them. To investigate the allegation, on 04/25/2023, interviewed (04) four staff and three (03) residents between 11:30 AM to 02:00 PM. During interviews with staff, all staff stated they check on residents frequently and residents are not left unattended for an extended time. During interviews with residents, Resident #2 (R2) stated that staff check on them frequently and do not leave them unattended for an extended time. Resident #3 (R3) and Resident #4 (R4) were non-responsive to interview questions.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Staff did not provide proper medication assistance to resident in care

It was alleged that resident was given medication over the allotted amount. To investigate the allegation, on 04/25/2023, requested documents at 10:30 AM and interviewed (04) four staff between 11:30 AM to 02:00 PM. Record review shows that the resident was given medication according to physician’s prescription. During interviews with staff, Staff #1 (S1) and Staff #3 (S3) stated they do not give more than the prescribed medication to residents. Staff #2 (S2) and Staff #4 (S4) stated they do not give medication to residents.

Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

(CONT. on LIC9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230417130206

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOME SWEET HOME II	FACILITY NUMBER: 197602143
	VISIT DATE: 06/04/2023

NARRATIVE

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--- Staff did not provide proper transfer assistance to resident in care

It was alleged that staff were witnessed not helping resident properly from the bed to a wheelchair, and vice versa. To investigate the allegation, on 04/25/2023, interviewed (04) four staff and three (03) residents between 11:30 AM to 02:00 PM. During interviews with staff, Staff #2 stated that they put resident’s wheelchair parallel to the bed, then put their arms under resident’s arms with their legs between resident’s legs to avoid back injury, then they lift and turn to position resident for a gentle seating. To transfer from wheelchair to bed, S2 stated that they use a blue sheet and put it on the side of the bed first, then hold the shoulder and simultaneously turn and that remaining steps are similar from bed to wheelchair, sit resident up and turn to the desired position. During interviews with residents, Resident #2 (R2) stated they have never seen residents being transferred. Resident #3 (R3) and Resident #4 (R4) were non-responsive to interview questions.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Staff do not provide proper food service to residents in care.

It was alleged that staff do not provide water or other fluids to drink throughout the day and night. To investigate the allegation, on 04/25/2023, interviewed (04) four staff and three (03) residents between 11:30 AM to 02:00 PM. During interviews with staff, all staff stated they provide water and requested drinks throughout the day. During interviews with residents, Resident #2 (R2) stated staff are providing water throughout the day and night and staff are continuously encouraging resident to drink water. Resident #3 (R3) and Resident #4 (R4) were non-responsive to interview questions.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2023

LIC9099 (FAS) - (06/04)

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