197606963-1-27-2021-28-AS-MVAO-BY3QN5-20210209111833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606963
Report Date: 01/26/2021
Date Signed: 01/27/2021 02:40:51 PM

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
11/09/2020 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201109171334

FACILITY NAME:	HOLY CARE HOME CENTER, INC		FACILITY NUMBER:	197606963
ADMINISTRATOR:	JAYSON SANDHU		FACILITY TYPE:	740
ADDRESS:	2709 CENTRAL AVENUE		TELEPHONE:	(626) 443-8993
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91732
CAPACITY:	30	CENSUS: 28	DATE:	01/26/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jayson Sandhu		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident suffered multiple falls resulting in injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via tele-video (Facetime) with the facility Administrator's Jayson Sandhu and Jasmen Raya.
Interviews were conducted today 1/26/2021 from 1:30 PM to 2:30 PM with Staff AJ Yapanura and Resident's 1-5.
Initial visit was conducted on 11/17/2020 and Administrator's Jayson Sandhu and Jasmen Raya were interviewed.
In regards to the allegation Resident suffered multiple falls resulting in injuries, Resident 1 was admitted to the facility on 3/25/2019. Physician's Report states Resident 1 is Ambulatory and able to bathe self, dress self, feed self, care for own toileting needs and manage own resources.
Based on interviews conducted and information gathered, Resident 1 stated that she has never fallen at this facility, but had fallen previous to being admitted to Holy Care. Stated that she believes she had a seizure

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

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-20201109171334

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: HOLY CARE HOME CENTER, INC	FACILITY NUMBER: 197606963
	VISIT DATE: 01/26/2021

NARRATIVE

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when she had fallen recently. Said that staff was fast to get to her and did a good job in getting her to the hospital.
Resident 1's roommate on 11/17/2020 stated she heard a thud and Resident 1 had fallen. Said she got staff who came right away. Said staff did the right thing.
Interviews with staff revealed that Resident 1 had not ever fallen at Holy Care. Also revealed that staff when alerted by roommate of Resident 1 came right away and called 911 right away when Resident 1 was disoriented.
Residents interviewed 1/26/2021 all revealed that they had not witnessed any falls and that staff is very good and always acts right away when called on for any problems they may have.

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

A telephonic exit interview was conducted with Administrator Jayson Sandhu, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

LIC9099 (FAS) - (06/04)

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