197605949-6-6-2022-28-AS-MVAO-CFES6Q-20220615133618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605949
Report Date: 06/06/2022
Date Signed: 06/06/2022 03:17:27 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, 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
11/17/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20211117085850

FACILITY NAME:	RETREAT, THE		FACILITY NUMBER:	197605949
ADMINISTRATOR:	AIMEE ARMENTA		FACILITY TYPE:	740
ADDRESS:	365 EL NIDO AVENUE		TELEPHONE:	(626) 356-2526
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	9	CENSUS: 4	DATE:	06/06/2022
		UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Ana Costa - Caregiver		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff is unable to provide appropriate care and supervision to a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA conducted a telephone call with Aime Armenta and explained the reason for the visit over the phone due to COVID 19 precautions.

The investigation consisted of the following: On 11/19/21 LPA Flores requested staff/resident roster,conducted a tour of the facility, no deficiencies were noted during the visit for physical plant. LPA interviewed resident #2(R2),#3(R3),#4(R4),#5(R5), reviewed files for Resident #1(R1), R3, and R5, requested copies of admission agreement, resident appraisal, physician's report, emergency and identification information, and appraisal needs and service plan for R1,R3,R5. LPA reviewed and requested copies of staff training for staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5). On 11/19/21 Administrator email LPA facility's plan of operation, incident report dated 11/19/21 and a copy of blank admission agreement. On 6/6/22 LPA Flores conducted a subsequent complaint investigation to deliver findings.

(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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-20211117085850

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: RETREAT, THE	FACILITY NUMBER: 197605949
	VISIT DATE: 06/06/2022

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff is unable to provide appropriate care and supervision to a resident. It is alleged R1 suffers from Dementia and Alzheimer's and renders at facility which is unable to effectively house and care for resident. Interviews with residents revealed 4 out of 5 residents stated to be assisted with care as needed and staff assists resident with reaching out to the physician when needed. LPA was unable to interview R1 due to R1 being at the hospital at the time of the visit. Interviews with staff revealed 3 out of 3 staff interview stated R1 had some behaviors and facility seek medical care upon staff observing behaviors, staff also stated to receive annual training on dementia care. Documents reviewed for R1 revealed R1 was admitted to the facility on 9/29/21, R1's last physician's report was conducted on 7/26/21 and diagnose correlates with diagnosis mention in the allegation. Incident report dated 11/19/21 notes facility contacted paramedics on 11/16/21 to request medical care for R1 due to behaviors, however resident was not transported. On 11/17/21 Per primary physician's request administrator reached out to San Gabriel Medical Center Psychiatric Emergency Team (PET), who came to the facility and evaluated R1 and provided assistance with transferring R1 to receive proper care. Facility's plan of operation has a Dementia Special Care amendment in place, Admission's Agreement dated 9/19/21 provides information regarding Advertising Dementia Special Care Provisions. Staff training was reviewed and facility provided 8 hours of dementia training on 2/13/21. On 11/19/21 LPA Flores conducted a tour of the facility and observed facility follows dementia physical plant requirements according to Title 22 regulations.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted with Ana Costa caregiver and a copy of this report was email to administrator.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC9099 (FAS) - (06/04)

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