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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609540
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:39:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2022 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20221230110826
FACILITY NAME:ROSE VALLEY ALTADENA IIFACILITY NUMBER:
197609540
ADMINISTRATOR:HSU, MICHAELFACILITY TYPE:
740
ADDRESS:2137 SANTA ANITA AVETELEPHONE:
(626) 765-6181
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 6DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michael Hsu, LicenseeTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff do not distribute residents' medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent visit to the facility to continue the investigation and to deliver the final findings of the above noted allegation. LPA met with Michael Hsu, Licensee. The purpose of the visit was explained.

During the investigation, on 1/06/2023 between 11:34pm and 12:25pm, LPA Laqueena Lacy spoke with the Administrator and other facility staff. At 12:05pm, LPA requested facility records. At 1:48pm, LPA Lacy spoke with two (02) out of five (05) residents. Three (03) residents were unable to respond to the questions. Prior to this visit, Licensing representatives reviewed the documents previously received from the Administrator. The documents included but not limited to residents' physician reports, pre-placement appraisals, needs and services plan, medication administration records, staff training records, and etc.

It was reported that on 12/28/2022 and 12/29/2022, night shift staff did not distribute night medications to
Continue on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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 6
Control Number 31-AS-20221230110826
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSE VALLEY ALTADENA II
FACILITY NUMBER: 197609540
VISIT DATE: 09/19/2023
NARRATIVE
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resident #2 (R2) and resident #3 (R3). Interviews of the staff present at the facility revealed that they dispense the medication as per physician orders. LPA Lacy made a few attempts to contact the night shift caregivers, but to no avail. A review of the medical administration records (MAR) conducted on 9/05/2023 at 11:30am revealed, that on 12/27/22 and 12/29/2022, R2's 10pm medications were not dispensed to the resident. R3 did not receive their 10pm medication on 12/29/2022.

Based on review of residents' MAR, there is sufficient information to conclude that staff did not distribute residents' medications as prescribed. Therefore, the allegation is SUBSTANTIATED at this time. Under Title 22, division 6, chapter 8 the following citation was issued and recorded on the LIC 9099D.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20221230110826
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE VALLEY ALTADENA II
FACILITY NUMBER: 197609540
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2023
Section Cited
CCR
87465(c)(2)
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87465 Incidential Medical and Dental Care. (c)(2) Once ordered by the physician the medication is given according to the physician's directions.


This requirement is not met as evidenced by:
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The Administrator will inform in writing about the actions she will take to ensure that residents medications are dispensed as per doctor's order. Written statement must be submitted to CCL within 24 hours.
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Licensee did not ensure that 2 residents' medications were dispensed as per Doctor's order. This poses an immediate health and safety risk to residents in care.
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2022 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20221230110826

FACILITY NAME:ROSE VALLEY ALTADENA IIFACILITY NUMBER:
197609540
ADMINISTRATOR:HSU, MICHAELFACILITY TYPE:
740
ADDRESS:2137 SANTA ANITA AVETELEPHONE:
(626) 765-6181
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 6DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michael Hsu, LicenseeTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Uncleared staff working with residents

Staff do not manage resident's behavior

Staff working with residents without required training

Licensee does not maintain facility in good repair

Staff do not assist resident with incontinence care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent visit to the facility to continue the investigation and to deliver the final findings of the above noted allegation. LPA met with Michael Hsu, Licensee. The purpose of the visit was explained.

During the investigation, on 1/06/2023 between 11:34pm and 12:25pm, LPA Laqueena Lacy spoke with the Administrator and other facility staff. At 12:05pm, LPA requested facility records. At 1:48pm, LPA Lacy spoke with two (02) out of five (05) residents. Three (03) residents were unable to respond to the questions. Prior to this visit, Licensing representatives reviewed the documents previously received from the Administrator. The documents included but not limited to residents' physician reports, pre-placement appraisals, needs and services plan, medication administration records, staff training records, and etc.

It was alleged that former staff #1 (S1) worked for the facility before receiving approved criminal record clearance and association. Staff #2 (S2) continued working for the facility without approved criminal record
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20221230110826
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSE VALLEY ALTADENA II
FACILITY NUMBER: 197609540
VISIT DATE: 09/19/2023
NARRATIVE
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criminal record clearance and/ or association. Interviews revealed that the Administrator does not allow staff to work in the facility without approved criminal record clearance and association to the facility. Upon review of the daily staff schedule and staff records, it appears that S1 has been working for the facility since 9/08/2022. A review of the Licensing Information System (LIS), shows that S1 and S2 both have fingerprint clearance and association to the facility. All staff working in the facility during this investigation had criminal record clearance.

Based on interviews and record review there is not sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

It was reported that staff do not manage resident's behavior. Resident #1 (R1) has behaviors of scratching, spitting, and fighting. Reporting party states that the licensee does not manage R1's behaviors. Staff are told to "leave her alone." Staff interviews revealed that R2 does not have behaviors. Due to their health condition, at times R2 is confused and agitated. However, caregivers are able to redirect R1. No staff complained about R1's behavior. A review of R1's facility records verified the information revealed from staff.
No other information or records were available to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

It was alleged that Staff #2 (S2) are distributing medication to residents however, S2 has not had medication training. During this investigation the Administrator stated that all staff working at the facility have received medication training. Staff also confirmed that they received medication training. On 9/07/2023 at 12:30pm, the Administrator e-mailed copies of staff training records, confirming the information revealed from the interviews.

Based on interviews and records review, there is no pertinent information to verify the allegation. Thus, the allegation is UNSUBSTANTIATED at this time.

It was reported that the toilet in the bathroom, which is designated for the residents, has been "stopped up" for two weeks. Reporting party states that staff have to use a plunger after each toilet use. Staff indicated that the bathroom toilet is functioning properly. Residents interviewed during the investigation did not address any concerns regarding facility toilets. At the time of licensing visits, bathrooms were inspected, and the toilets were functional and in good repair.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20221230110826
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSE VALLEY ALTADENA II
FACILITY NUMBER: 197609540
VISIT DATE: 09/19/2023
NARRATIVE
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Based on inspection, observation, and interviews, there is no pertinent information to verify this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

It was alleged that R2 and Resident #5 (R5) have not had a shower since September of 2022. Staff revealed that the resident is getting showered every Tuesday and Friday. If resident refuses, then they ask the next day. Residents interviewed during the investigation did not have any concerns regarding their shower assistance. At the time of the investigation, LPAs observed all residents residing at the facility and they were clean and well groomed. During the facility inspection, LPAs did not smell urine.

Based on inspection, observation, and interviews, there is not sufficient information to verify the allegation. Thus, the allegation is UNSUBSTANTIATED at this time.

It was alleged that R1 smells bad and was left in soiled diapers. Staff revealed that all facility residents requiring incontinent care are being checked every 2 hours, at times even sooner. Residents interviewed during the investigation did not address any concerns about their incontinent care. R1 was unable to respond to the questions due to their health condition affecting their speech. At the time of this visit LPA Valenzuela observed that facility staff assist residents with toileting and they were clean and groomed. LPA did not smell urine or other foul odors.

Based on observation, interviews, and records review, there is an insufficient amount of information to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety hazard is noted during this visit.

Exit interview was conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6