197609821-10-17-2023-31-AS-EMIR-CZQV5X-20240122150839

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609821
Report Date: 10/17/2023
Date Signed: 10/17/2023 01:45:38 PM

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
11/02/2020 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20201102093332

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:	10/17/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Merlita Nepomuceno		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not meet the needs of the resident.
Illegal Eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent complaint visit for further investigation and to deliver determinations on the allegations mentioned above. LPA met with the administrator Merlita Nepomuceno and the purpose of the visit was explained. On todays visit LPA Rios conducted further interviews with Nathan via telephone at 11:18 a.m. and interviewed Marlita again at approximately 11:40 a.m.

Allegation #1: Staff did not meet the needs of the resident.
It is alleged resident #1 (R1) could not feed themselves and staff did not assist. To investigate the allegation on 11/06/2020 due to the COVID-19 pandemic, LPA Shanahan meet with Nathan Nepo via Facetime. On 10/10/2023 LPA Rios met with administrator Merlita Nepomuceno at the facility and spoke with the licensee Nathan Napo via telephone. LPA Rios also interviewed staff present and attempted interviews with residents at approximately 12:40 p.m. At 3:40 p.m. LPA Rios obtained and reviewed, R1’s, Appraisal/Needs and Services Plan, Physician’s Report, Reappraisal, Unusual Incident/Injury Report and facility Progress Notes. (Continued to LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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-20201102093332

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: A HOME FOR YOU	FACILITY NUMBER: 197609821
	VISIT DATE: 10/17/2023

NARRATIVE

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R1's, Physician's Report dated 03/04/2020 revealed R1 was "able to feed self", Appraisal dated 03/04/2020 reported R1 did not need help with eating. Interviews with the licensee revealed R1 had started to refuse to eat and he notified R1's family. According to the licensee, the facility had open communication with R1's family, informing them of R1's refusals. LPA reviewed facility progress notes from 03/20/2020 to 10/10/2020, notes revealed R1's refusals and the times R1's "family was made aware". According to the licensee, staff assisted R1 with eating but it was not "total care". Furthermore, interviews with the administrator and other staff revealed R1 had refused assistance for various things such as repositioning, incontinent care and eating. According to the licensee, due to residents decline in health and change in condition a Reappraisal and Appraisal/Needs and Services dated 10/07/2023 were conducted and facility noted R1 needed help with eating. R1 was transferred out of the facility on 10/10/2020. LPA Rios attempted to contact R1's family but was unsuccessful. Based on the information obtained, there was insufficient evidence to corroborate the allegation staff did not meet the needs of the resident. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation #2: Illegal Eviction.
It is alleged the licensee refused to take the resident #1 (R1) back on two different occasions when R1 was discharged from the hospital. To investigate the allegation LPA conducted interviews with the licensee and the administrator on 10/10/2023 and 10/17/2023. According to the licensee, R1 was never evicted. On the first occasion the facility was notified by the hospital that R1 was ready for discharge but the facility felt R1's wound was not getting better. Licensee notified R1's family, that it would be best for R1 to be in a "24/7 nursing care". Licensee states they did admit R1 back to the facility after both of R1's hospital discharges and continued to encourage R1's family to consider skilled nursing services because the facility and the wound care nurse believed R1's wound was not improving and the facility could not "address R1's current needs". According to licensee an eviction notice was not issued and unnecessary because R1's family decided to transfer R1 to "another board and care". Based on the information obtained, there was insufficient evidence to prove that R1 was Illegally Evicted. Therefore, the allegation is deemed Unsubstantiated at this time.

Administrator advised and a copy of this report issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC9099 (FAS) - (06/04)

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