197607902-10-21-2022-28-AS-FFIS-CQ92Z4-20230324174942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607902
Report Date: 10/21/2022
Date Signed: 10/21/2022 02:41:46 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
10/19/2022 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221019161248

FACILITY NAME:	ST. MICHAELS HOME FOR THE ELDERLY		FACILITY NUMBER:	197607902
ADMINISTRATOR:	JAMES MCGEE		FACILITY TYPE:	740
ADDRESS:	1506 S. CANDISH AVENUE		TELEPHONE:	(951) 532-4644
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY:	6	CENSUS: 6	DATE:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Barbara Boiston- Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility staff member is physically abusing resident while in care.
Facility staff member threatens to kill resident while in care.
Facility staff are not ensuring that resident takes their medication while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an initial complaint visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with caregivers Angelina Tupil and Edgardo Quimbao and explained the purpose for the visit. The staff immediately contacted Barbara Boiston who then joined LPA Maldonado for the visit.

During today's visit, LPA Maldonado requested a copy of the resident and staff roster, and the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Medication Administration Records (MARs), and Pre-Placement Appraisal and current appraisal. LPA Maldonado also conducted a tour of the physical plant with adminstrator Barbara Boiston and conducted interviews with Residents# 1-6 (R1-R6), Staff# 1-3 (S1-S3).

(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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-20221019161248

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: 10/21/2022

NARRATIVE

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Regarding allegation: Facility staff member is physically abusing resident while in care.
During interviews conducted with S1-S3, staff stated that on 10/19/22, the police arrived at the facility regarding the allegation. Allegedly S3 hit R1 with S3 hands while R1 slept. A police officer investigated the allegations and provided and incident report number. During the investigation with the police, R1 declined the allegations and stated that staff treat R1 well. (3) of (3) staff stated that R1 has made similar allegations in the past about other residents, but it was investigated and was determined to not be true. Staff denied allegations and stated that R1 constantly asks S3 for assistance. During the interview conducted with R1, LPA observed the resident and no marks/burises/cuts consistent with the allegation were noted. R1 states that S3 goes in R1's room everyday at 5AM to hit R1 on R1's left side, including R1's heart, rib cage and stomach. R1 then stated that they noted bruises on their stomach, but also stated the bruises could possibly be from R1's insulin shots- R1 was not sure what the bruises were a result of. During interviews conducted with R1-R6, (5) of (6) residents state that staff treat them well. Residents also stated they have not witnessed nor have knowledge of staff physically abusing a resident in care.

Regarding allegation: Facility staff member threatens to kill resident while in care.
During interviews conducted with S1-S3, (3) of (3) staff denied the allegation. S1-S3 state that the police also investigated this allegation on 10/19/22 and determined it did not occur. Staff state that R1 has made this allegation in regards to S3 for unknown reasons. During interviews conducted R1-R7, (6) of (7) residents state they have not witnessed or have knowledge of staff threatening to kill a resident in care. R1 stated S3 has placed spiders and scorpions in R1's room and told the spiders to kill/hurt R1. LPA toured the room where R1 resides and did not observe any cobwebs/droppings indicating that any spiders or scorpions would be present in and throughout the room.

Regarding allegation: Facility staff are not ensuring that resident takes their medication while in care.
During interviews conducted with S1-S3, all staff stated that R1 will refuse to take some medications from time to time. R1 is encouraged to take all medications and any time it has been refused, the responsible party and physician have been notified. During interviews conducted with R1-R7, R1 admitted to not taking some medications because of the way it would make R1 feel; However the medications that R1 was refusing to take have been changed per doctors orders and R1 has been compliant. Per MARs, resident has not refused any medications for the month of October 2020.

(Report Continued on LIC9099-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221019161248

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: 10/21/2022

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	Although the allegations 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.. An exit interview was conducted with Administrator Barbara Boiston and a copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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