<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607902
Report Date: 08/28/2020
Date Signed: 08/28/2020 12:01:41 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
08/20/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200820161756
FACILITY NAME:ST. MICHAELS HOME FOR THE ELDERLYFACILITY NUMBER:
197607902
ADMINISTRATOR:JAMES MCGEEFACILITY TYPE:
740
ADDRESS:1506 S. CANDISH AVENUETELEPHONE:
(951) 532-4644
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 4DATE:
08/28/2020
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Barbara Boiston, House ManagerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff threatened resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vasallo 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 telephonically with Barbara Boiston, manager.

LPA Vasallo conducted telephone interviews and used video call to interview 3 staff and 5 residents in the facility. Resident #1's (R1) family was also interviewed. During the video call LPA observed the residents' bedrooms and common areas. LPA requested and obtained the names of all residents and staff.

The investigation revealed the following: It's alleged staff threatened R1 with physical harm and also asked a resident to harm R1. Staff interviewed deny the allegation. Staff have not witnessed any abuse or have any knowledge of abuse. R1 was interviewed using video call. R1 did not appear to have any injuries. R1 indicated she was also interviewed by police and a social worker.
Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2020
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 2
Control Number 28-AS-20200820161756
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: ST. MICHAELS HOME FOR THE ELDERLY
FACILITY NUMBER: 197607902
VISIT DATE: 08/28/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews were attempted with the other 3 residents in the facility using video call. However, insufficient information was obtained due to their cognitive impairment. Residents did not appear to be in any distress. R1's family member was interviewed. The family member indicated R1 has been having increased hallucinations recently about people trying to harm him/her. The family member did not feel the allegations were valid. There is no physical evidence of abuse and there were no witnesses to the alleged abuse.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. A telephonic exit interview was conducted with Barbara Boiston, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2