197605266-6-14-2023-31-AS-TAGD-CTGLVK-20230706090541

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605266
Report Date: 06/14/2023
Date Signed: 06/14/2023 04:15:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
06/05/2023 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20230605090134

FACILITY NAME:	JMJ GUEST HOME		FACILITY NUMBER:	197605266
ADMINISTRATOR:	LUCIA DELA REA		FACILITY TYPE:	740
ADDRESS:	43905 ELM AVENUE		TELEPHONE:	(661) 940-5550
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	6	CENSUS:	DATE:	06/14/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	LUCIA DELA REA		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff member physically abused resident while in care
Resident sustained a fall while in care
Staff failed to meet resident's needs

INVESTIGATION FINDINGS:

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On 6/14/2023 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by Lucia Dela Rea.

The investigation consisted of the following: On 6/12/2023, LPA Spaeth conducted a 10-day visit, toured the physical plant and requested documents. LPA Spaeth requested the following documents: 1) staff and resident roster, and 2) R5’s physician report. All documents were received at the time of visit. LPA Spaeth interviewed R2, R3, and R5. R1 and R4 were unable to answer LPA’s questions.

The investigation revealed the following
Regarding the allegation, staff member physically abused resident while in care, it is alleged a caregiver had physically abused resident in care by punching and slapping the resident on 5/10/2023t. LPA interviewed R2 and R3 who stated staff has never slapped or punched them. R5 stated S1 and Administrator has never

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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-20230605090134

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: JMJ GUEST HOME	FACILITY NUMBER: 197605266
	VISIT DATE: 06/14/2023

NARRATIVE

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slapped or punched them. R5 stated a caregiver from a private resident had slapped and punched them on May 10, 2023. R5 lived at the private resident before moving to JMJ Guest Home. R5 stated moved into facility on May 22, 2023. . LPA interviewed caregiver and Administrator who both stated has never slapped or punched a resident.

Regarding the allegation, resident sustained a fall while in care, it is alleged that resident sustained injuries due to a fall. R2, R3, and R5 stated have not fallen during the month of May, 2023 and June, 2023. The Caregiver and the Administrator stated residents have not fallen in the past two months.

Regarding, staff failed to meet resident’s needs, it is alleged that resident fell due to the neglect of caregivers. R2, R3, and R5 stated staff has met resident’s needs. The Caregiver and Administrator both stated have met residents' needs. Administrator stated residents have not complained about the care they have received.

Based on LPA’s interviews conducted, the preponderance of evidence standard has not been met. Although the allegation(s) 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 allegations are unsubstantiated.

An exit interview was conducted, and a copy of the report was given.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

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