197608358-11-10-2021-28-AS-WSHO-C9WTDD-20211221133811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608358
Report Date: 11/10/2021
Date Signed: 11/10/2021 02:37:07 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
11/05/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211105140815

FACILITY NAME:	LA POSADA IN SAN DIMAS		FACILITY NUMBER:	197608358
ADMINISTRATOR:	LUCY PARKER		FACILITY TYPE:	740
ADDRESS:	1452 GOLDRUSH STREET		TELEPHONE:	(909) 599-2273
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 6	DATE:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	11:59 AM
MET WITH:	Administrator, Lucy Parker		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility is over capacity.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegation listed above. LPA met with Administrator, Lucy Parker and explained the reason for the visit.

The investigation consisted of the following: Interviews were conducted with three staff and one resident. The facility was toured and resident roster was reviewed.

The investigation revealed the following: It's alleged facility is caring for more than six residents which is beyond the allowed capacity of six. The facility was toured and seven beds were observed in the facility. The resident roster was reviewed and it indicated there were six residents. However, a seventh individual was lying on a hospital bed asleep in a resident's room. Both caregivers were interviewed and they indicated that individual doesn't live at the facility, but the individual arrives with the Administrator and leaves with the Administrator. Caregivers indicated they do provide care to the individual by assisting with toileting and feeding. The individual is also on hospice. Staff indicated the hospice nurse visits the facility to treat this individual. Continued on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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-20211105140815

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: LA POSADA IN SAN DIMAS	FACILITY NUMBER: 197608358
	VISIT DATE: 11/10/2021

NARRATIVE

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Staff report this individual has been visiting for a couple of months and usually visits the facility Monday - Friday. The resident interviewed confirmed the individual spends a lot of time at the facility and thought the individual lived there. The resident has seen staff provide care to the individual. There are six residents residing in the home and the seventh individual also needs care and supervision which facility staff is providing. Staff also confirmed the individual is on hospice and the hospice nurse visits the facility to provide care.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held. A copy of the report, civil penalty form and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20211105140815

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: LA POSADA IN SAN DIMAS	FACILITY NUMBER: 197608358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/12/2021 Section Cited CCR 87204(a)	1 2 3 4 5 6 7	Limitations - Capacity and Ambulatory Status: (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time.	1 2 3 4 5 6 7	Administrator said the individual will no longer visit the facility. The seventh bed will be removed from the bedroom. Administrator will send proof the bed was removed. This deficiency will result in an immediate civil penalty for operating beyond the approved capacity.
	8 9 10 11 12 13 14	Deficiency was evidenced by the following: Seven beds were observed in the facility and an individual not on the roster was present. Individual was observed asleep in a hospital bed with full rails. Staff confirmed they provide care to the individual and residents have also seen staff provide care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC9099 (FAS) - (06/04)

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