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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603680
Report Date: 06/15/2023
Date Signed: 06/15/2023 09:44:52 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
02/16/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220216120626
FACILITY NAME:HAMPTON GUEST HOME, INC.FACILITY NUMBER:
197603680
ADMINISTRATOR:YANG, ERLINDAFACILITY TYPE:
740
ADDRESS:3790 HAMPTON RD.TELEPHONE:
(626) 351-1215
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 6DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jeff Yang - Assistant Administrator TIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Resident sustained severe fracture while in care
Staff did not seek medical attention for resident
INVESTIGATION FINDINGS:
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13
*This report is a corrected version of report created on 6/6/23. The purpose of this report is to correct information on report.*

On 6/6/23 Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced subsequent complaint visit regarding the above allegation(s) to deliver findings. LPA met with and explained the reason for the visit.

The investigation consisted of the following: On 2/17/22 LPA Flores conducted a Health and Safety Check tour with staff #4(S4) around 9:50am deficiencies were cited on a case management. On 2/16/22 Investigation was assigned to Investigator Tiffany Brunelli from the Investigator Bureau Department. On 3/28/22 LPA Flores, and IB investigator conducted an unannounced visit to review medication for current residents and resident #1(R1).
(CONTINUED LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
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 6
Control Number 28-AS-20220216120626
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680
VISIT DATE: 06/15/2023
NARRATIVE
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IB investigator conducted interviews with staff #1(S1) and #2(S2) and requested copies of documents in R1's file. On 4/4/22 IB investigator interviewed staff #3(S3). On 4/8/22 IB investigator interviewed resident #2(R2), administrator, and S4. On 11/4/22 a clinical consult referral was submitted to the department's clinical program. On 6/6/23 LPA conducted interviews with 3 additional residents.

The investigation revealed the following: Regarding allegations: Resident sustained severe fracture while in care and staff did not seek medical attention for resident. On 1/19/22 at approximately 10:00 am, R1 fell in R1’s bedroom. Staff contacted administrator and notified administrator of R1's fall. R1 was assisted by staff and administrator to seat in a stool. R1 was then transferred to a wheelchair to assist R1 to move to a sofa located in the family room. R1’s responsible party was notified of the fall that day. On 1/21/22, R1's responsible party visited R1 and noticed R1 was in pain. Responsible party communicated with administrator about obtaining an x-ray for R1. On 1/22/22, physician visited R1 and requested a mobile x-ray unit. X-ray confirmed R1 had sustained a moderately displaced subcapital left hip fracture. R1 was placed on hospice per responsible party's request. On 1/29/22, R1 passed away at the facility.

Interviews conducted revealed administrator did not believe R1 obtained an injury at the time of the fall. On 1/19/22 around noon, administrator contacted R1's responsible party to notify them of R1's fall and bruising to the knee. Administrator noticed R1 could no longer bare weight on leg and transferred R1 into a wheelchair. Administrator did not assist with contacting physician until R1's responsible party requested on 1/21/22. S4 was interviewed and stated R1 was observed in bed, in pain, and moaning when moved to provide care. While providing a shower, staff noticed a bruise on R1's knee and noticed R1 moaned during the shower. S3 stated R1 fell on 1/19/22 around 9:30am. Staff responded and noticed R1 was crying but did not appear to have injuries. S2 stated the morning prior to the fall, R1 was able to ambulate with supervision to R1's room. About 15 minutes later S2 heard S3 request additional assistance to assist R1 in the bedroom. On 1/20/22, S2 began the morning shift and went to assist R1 with care and noticed R1 was in pain. S2 asked R1, "are you in pain?" to which R1 responded "a little bit," and pointed to the top of his/her leg. R1’s last physician's report dated 4/26/19 notes resident does not have any motor impairment. Needs and care service plan dated 7/18/18 notes resident is able to ambulate with some assistance, no updates are noted in most recent needs and care plan dated 1/3/22. Hospice admission and nursing home notes dated 1/22/22 indicates R1 was admitted to hospice due to hip pain and a possible hip fracture. Based on interviews conducted and documents reviewed, R1 suffered a fracture while in care and administrator failed to obtain medical care for R1 in a timely manner. (CONTINUED ON LIC 9099C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20220216120626
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680
VISIT DATE: 06/15/2023
NARRATIVE
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Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustained a subcapital left hip fracture while in care. Refer to LIC 421IM***

The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the serious bodily injury was due to neglect.

Exit interview held with Jeffrey Yang Assistant Administrator. A copy of the report, civil penalties, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20220216120626
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities shall...:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidence by:
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Administrator will schedule in-service training for staff and notify the department by POC due date 6/7/23. Administrator will provide copies of in-service training by 6/14/23. Administrator provided in-service training on 6/13/23. Deficiency cleared as of 6/14/23.
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Based on interviews and document review R1 obtained a hip fracture after a fall while in care at the facility which poses an immediate personal rights, safety, or health risk to the persons in care.
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Type A
06/16/2023
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental: (a) A plan for incidental medical...shall be developed... and provide for assistance... (1) The licensee shall arrange, or assist in arranging, for medical...care appropriate to the conditions... of residents.
This requirement is not met as evidence by:
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Administrator will schedule in-service training for staff by and notify the department by POC due date 6/7/23. Administrator will provide copies of in-service training by 6/14/23. Administrator provided in-service training on 6/13/23. Deficiency cleared as of 6/14/23.
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Based on interviews and document review licensee did not ensure to obtain medical care for R1 in a timely manner which poses an immediate risk to the health, safety, or personal rights to the persons in care.
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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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
02/16/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220216120626

FACILITY NAME:HAMPTON GUEST HOME, INC.FACILITY NUMBER:
197603680
ADMINISTRATOR:YANG, ERLINDAFACILITY TYPE:
740
ADDRESS:3790 HAMPTON RD.TELEPHONE:
(626) 351-1215
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 6DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jeff Yang - Assistant AdministratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are force feeding resident's
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*This report is a corrected version of report created on 6/6/23. The purpose of this report is to correct information on report.*

On 6/6/23 Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced subsequent complaint visit regarding the above allegation(s) to deliver findings. LPA met with and explained the reason for the visit.

The investigation consisted of the following: On 2/17/22 LPA Flores conducted a Health and Safety Check tour with staff #4(S4) around 9:50am deficiencies were cited on a case management. On 2/16/22 Investigation was assigned to Investigator Tiffany Brunelli from the Investigator Bureau Department. On 3/28/22 LPA Flores, and IB investigator conducted an unannounced visit to review medication for current residents and resident #1(R1).
(CONTINUED LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20220216120626
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680
VISIT DATE: 06/15/2023
NARRATIVE
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IB investigator conducted interviews with staff #1(S1) and #2(S2) and requested copies of documents in R1's file. On 4/4/22 IB investigator interviewed staff #3(S3). On 4/8/22 IB investigator interviewed resident #2(R2), administrator, and S4. On 11/4/22 a clinical consult referral was submitted to the department's clinical program. On 6/6/23 LPA conducted interviews with 3 additional residents.

The investigation revealed the following: Regarding allegation: Staff are force feeding residents. It is alleged facility's staff is force feeding resident at facility. Interviews conducted revealed, resident #2 (R2) interviewed on 4/8/22 stated staff does not force feed residents. Interviews conducted on 6/6/23 with 3 additional residents revealed staff do not force feed the residents. Interviews with staff revealed 4 out of 5 staff interviewed stated staff do not force feed residents and followed instructions of not feeding R1 if resident did not want to eat. Administrator stated facility staff does not force feed residents. Based on interviews conducted there are no witnesses to this allegation, and nobody corroborated the allegation.

Based on interviews, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Jeffrey Yang Assistant Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6