197607962-10-6-2022-28-AS-RORN-CKBRHW-20221018130257

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607962
Report Date: 10/06/2022
Date Signed: 10/06/2022 01:01:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
09/29/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220929161850

FACILITY NAME:	QUEEN OF THE ANGELS ASSISTED LIVING INC.		FACILITY NUMBER:	197607962
ADMINISTRATOR:	TERRY & MARY MCGEE		FACILITY TYPE:	740
ADDRESS:	420 S. MANNINGTON PLACE		TELEPHONE:	(626) 430-7702
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	6	CENSUS: 6	DATE:	10/06/2022
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Joel Basillo & Maryanne Vergara (Caregivers)		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is not following COVID-19 protocols.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegation. LPA met with Joel Basillo and Maryanne Vergara (Caregivers) and explained the reason for the visit. The Administrator Terry McGee showed up shortly after.

The investigation consisted of the following: LPA obtained copies of the resident and staff rosters, and interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 - Resident 6 (R1 - R6), and some family members and visitors that visited the facility in September.

The investigation revealed the following: regarding the allegation "facility is not following COVID-19 protocols”, it is alleged that the visitor log shows multiple visitor's temperatures were not recorded and missing
from the log.
(CONTINUED TO LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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-20220929161850

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: QUEEN OF THE ANGELS ASSISTED LIVING INC.	FACILITY NUMBER: 197607962
	VISIT DATE: 10/06/2022

NARRATIVE

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Administrator and staff interviewed denied the allegation and stated that all visitors are Covid-19 screened and their temperature is taken. They provide the temperature to the visitors and ask them to complete the visitor log. Residents interviewed revealed that 3 out of 6 residents were unable to corroborate the allegation. An attempt to interview the other 3 residents was made but was unsuccessful due to either being asleep, refusing to be interviewed or intellectual capabilities. Interviews with the family members revealed that they are Covid-19 screened and their temperature is taken when they come visit. They are asked to complete the visitor log. LPA contacted the visitors that have a missing temperature in the September visitor log and they all confirmed that they were Covid-19 screened and their temperature was taken. However, they forgot to write down their temperature in the visitor log. Facility will ensure from now on that the visitors fully complete the visitors log. In today's visit, the LPA was Covid-19 screened at the entrance and temperature was taken. The staff provided the LPA with the temperature and asked the LPA to complete the visitor log.

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.

Exit interview held and a copy of the report was provided

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

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