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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609642
Report Date: 05/26/2022
Date Signed: 05/26/2022 03:36:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/13/2022 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20220113101728
FACILITY NAME:J28 HOME CARE CORPFACILITY NUMBER:
197609642
ADMINISTRATOR:FRANCIS MARTIRFACILITY TYPE:
740
ADDRESS:20702 KITTRIDGE STTELEPHONE:
(714) 305-2110
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:0CENSUS: DATE:
05/26/2022
UNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Susan OlaliaTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Resident had to be hospitalized for hypothermia while in care
Resident sustained a fall while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava was assigned this complaint to conclude the investigation regarding the above allegations. It was reported that Resident 1 (R1) was admitted to the hospital with a bad temperature of 30 degrees C and suffered from hypothermia, alleging resident may have been neglected by facility staff and left outside of the facility. The initial 10 day visit to the facility to investigate this complaint was conducted by LPA Nicholas Reed. It was then referred and assigned to Investigations Branch (IB) Investigator Dennis Douglas on January 14, 2022. During the course of IB’s investigation, interviews and record review were conducted by Investigator Douglas.

IB’s investigation reveal that although it could not be proven through interviews with facility staff and resident families that R1 suffered hypothermia and sustained a fall due to neglect, there is pertinent information by the treating physician that indicates “per history and physical pt’s rectal temperature, which was at 30 degrees Celsius, neglect
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
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 3
Control Number 31-AS-20220113101728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: J28 HOME CARE CORP
FACILITY NUMBER: 197609642
VISIT DATE: 05/26/2022
NARRATIVE
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would cause the patient to be hypothermic. The patient presents with injury sustained due to fall. The onset was unknown. The course of the symptoms is constant”.

Based on the information obtained, the allegations are Substantiated. Citation(s) issued on the 9099D.

Note that this facility has closed on 3/16/22.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220113101728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: J28 HOME CARE CORP
FACILITY NUMBER: 197609642
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2022
Section Cited
CCR
87464(f))(1)
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Basic Services: “Care and supervision” means the facility assumes responsibility for, or provides ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
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Facility closed on 3/16/22. No POC required at this time since the licensee has ceased operation.
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This requirement has not been met as evidenced by the licensee allowing for R1 to suffer from hypothermia and a fall. This poses as an immediate health and safety risk to the resident 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3