197609821-1-26-2023-31-AS-RRAZ-CQ7NCP-20230323102101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609821
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:26:42 PM

Unsubstantiated

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
03/08/2022 and conducted by Evaluator Melissa Ruiz

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220308110716

FACILITY NAME:	A HOME FOR YOU		FACILITY NUMBER:	197609821
ADMINISTRATOR:	NEPOMUCENO, MERLITA		FACILITY TYPE:	740
ADDRESS:	43845 GENERATION AVE		TELEPHONE:	(818) 357-8667
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 4	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Nathan Nepomuceno		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Physical Abuse

INVESTIGATION FINDINGS:

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On 1/26/2023, Licensing Program Analyst (LPA) Melissa Ruiz conducted a subsequent complaint visit for the purpose of issuing the completed investigative report conducted by CCL’s Investigative Branch (IB). On 3/08/22, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s, Investigation Branch as an assignment to obtain relevant information. The complaint was accepted by CCL IB and was assigned to Investigator Lorraine Patterson. LPA met with the Administrator Nathan Nepomuceno and the purpose of the visit was explained.

On 03/09/22 LPA Shanahan conducted an unannounced visit and collected relevant documents pertaining to the allegation. IB Investigator Patterson conducted file review and interviews from 03/11/20220 – 03/22/2022 with various witnesses. IB Investigator Patterson conducted a visit on 05/17/22 and during that visit, conducted interviews with two (2) residents, and the Administrator.

(cont. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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 31-AS-20220308110716

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: A HOME FOR YOU	FACILITY NUMBER: 197609821
	VISIT DATE: 01/26/2023

NARRATIVE

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It is alleged that R1 sustained physical abuse while in care. Investigation revealed that on 03/04/22, R1 arrived at the facility via ambulance from R1’s former care. R1’s son was also present during R1’s admission. An interview conducted with facility Administrator on 5/17/2022, revealed that R1 did not have a fall or incident on the day of their arrival. An interview with R1’s son on 3/22/2022, revealed that he was there when R1 was transported to the facility via gurney. R1’s son stated he did not observe R1 to be in any pain, nor did R1 report any pain. R1’s son stated he does not believe R1 sustained any physical abuse at the facility but was injured during transport from R1’s former care to the facility. An interview with medical personnel, revealed that they could not assess where R1’s bruising came from, but that it “could be considered consistent with being held or moved” in a “bear hug”. Interviews conducted with two (2) residents on 5/17/2022, revealed that both residents feel same and comfortable living at this facility. Both deny seeing or experiencing any abuse or neglect.

Record review revealed that staff documented various observations dated from 3/4/2022 – 3/8/2022 regarding R1. On 3/4/2022, staff documented R1’s arrival via gurney and noted, “There is redness on the right upper quadrant/ and under the breast.” On 3/05/2022, staff noted that R1 had bruising in the abdomen, at the same place where the redness was observed on 3/4/2022. On 3/7/2022, staff noted that the abdominal bruising was extended to R1’s breast/chest area. R1’s son was notified and R1’s physician was called, to which R1’s physician instructed staff to send R1 to the Emergency Department. Staff called 911, and R1 was transported to AV Hospital. On 3/8/2022, staff documented R1’s discharge from AV Hospital, and staff annotated “no significant findings”. Record review also revealed that there was a LASD police report, to which showed that Deputies arrived at AV Hospital on 3/8/2022. Police report reflects that a Deputy spoke to R1, to which R1 stated that they believed that being picked up and moved caused their injuries. Deputies were unable to determine if a crime occurred.

Due to a lack of supporting evidence and interviews, the allegation that resident sustained physical abuse is unsubstantiated at this time. No deficiencies issued. Exit interview conducted. Report signed and delivered. Appeal rights delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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