197609540-5-30-2023-31-AS-EMIR-D3QRT6-20240326131750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609540
Report Date: 05/30/2023
Date Signed: 05/30/2023 11:56:01 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/22/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230522155832

FACILITY NAME:	ROSE VALLEY ALTADENA II		FACILITY NUMBER:	197609540
ADMINISTRATOR:	HSU, MICHAEL		FACILITY TYPE:	740
ADDRESS:	2137 SANTA ANITA AVE		TELEPHONE:	(626) 765-6181
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	6	CENSUS: 5	DATE:	05/30/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Yessica Iscoa- Lead Caregiver		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not have enough staff to meet the needs of resident’s activities of daily living.
Staff do not provide activities for resident while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 5/30/23 Licensee Program Analysts (LPAs) Mariana Agban and Michael Cava arrived at 9:30 AM
at the above facility. LPAs conducted a complaint visit to facility to investigate the above allegations. During the course of the investigation, LPAs interviewed staff, residents, and observed the common areas to insure activities are being provided, and that facility has an adequate amount of hygiene and incontinent supplies.

Facility does not have enough staff to meet the needs of the resident's activities of daily living:
In regards to the allegations it was being alleged that the facility doesn't have enough staff to enure that residents hygiene needs, toileting needs and response to residents requests for assistance are being met. Investigation consist of interviews with administrator, staff, and residents. In addition to these interviews LPAs conduct a record review of resident toileting and hygiene needs. Furthermore, LPAs conducted a physical plant inspection to ensure that the facility has an adequate supply hygiene and incontinent supplies.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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 2

Control Number 31-AS-20230522155832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE VALLEY ALTADENA II	FACILITY NUMBER: 197609540
	VISIT DATE: 05/30/2023

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 with the administrator and staff denied the allegation of staff not being able to met the resident needs. LPAs attempted to interview five (5) out five residents but they weren't responsive to LPAs questions. LPAs reviewed facility records for the resident's daily bathroom log for the morning and evening to insure that all residents are being checked constantly for incontinent care as facility is providing care and supervision for residents that are diagnosed with dementia, and Resident 1's (R1) files. Per inspection of the physical plant, LPAs observed an adequate amount of hygiene and incontinent products. LPA's also observed two (2) staff and the administrator being able to provide care and supervision to all five of the residents needs. Based on the information provided, there was insufficient evidence to prove that the facility does not have enough staff to meet the resident's needs. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff do not provide activities for resident while in care:
In regards to the allegation the investigation consisted of interviews with residents and staff, review of the facility activity calendar, and a physical plant inspection to insure activities are being held. Interviews with the administrator and staff deny the allegation of activities not being provided. LPAs attempted to interview five (5) out of five residents, but they weren't responsive to the LPAs questions. LPAs did conduct a physical plant inspection, and observed two (2) residents participating in virtual exercise in the living room. Three (3) residents declined to participate. LPAs obtained a copy of the facilities monthly activity weekly calendar for record and review. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not providing activities for residents while in care. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2