197606868-9-15-2020-31-AS-CHAS-BU6UJH-20201007153734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606868
Report Date: 07/06/2020
Date Signed: 09/15/2020 09:10:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
05/08/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20200508164612

FACILITY NAME:	GUMA RESIDENTIAL CARE FOR THE ELDERLY		FACILITY NUMBER:	197606868
ADMINISTRATOR:	VIRGINIA GUMAYAGAY		FACILITY TYPE:	740
ADDRESS:	544 WEST AVENUE J-15		TELEPHONE:	(661) 941-2422
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	6	CENSUS: 2	DATE:	07/06/2020
		UNANNOUNCED	TIME BEGAN:	03:11 PM
MET WITH:	Virginia Gumayagay		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff member yelled at resident
Staff member failed to follow resident’s advanced director

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Spaeth initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted by a telephone call with Virginia Gumayagay, the facility administrator of Guma Residential Care for the Elderly. Since the Administrator does not have access to FaceTime or other virtual technologies, the investigation findings were conducted by a telephone call.

It was reported that a staff member yelled at a resident. LPA Spaeth interviewed a resident, Administrator, staff member, and resident’s family member regarding the allegation. All parties stated never wtinessed a staff member yelling at residents. A resident’s family member stated staff members have always been kind and considerate to family member’s father. Resident (R2) was interviewed and asked if a staff member has yelled at R2. R2 stated no. Based upon the statements for the above-referenced individuals, this allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2020

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-20200508164612

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: GUMA RESIDENTIAL CARE FOR THE ELDERLY	FACILITY NUMBER: 197606868
	VISIT DATE: 07/06/2020

NARRATIVE

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It was reported that a staff member failed to follow resident’s advanced directives. LPA Spaeth spoke to Administrator and R1’s family member regarding the incident reported on January 20, 2020. Administrator stated CPR was not administered to R1 and R1s family member stated R1 had not mentioned the incident to family member. Complainant had stated Administrator had stated to Complainant that CPR was administered. However, Administrator had stated Administrator did not state this to Complainant. Based upon LPA’s interviews with staff member, family member, and the administrator, this allegation is unsubstantiated.
Exit interview was concluded.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2020

LIC9099 (FAS) - (06/04)

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