197610195-5-14-2024-31-AS-TAGD-D6SL92-20240702083250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610195
Report Date: 05/14/2024
Date Signed: 05/14/2024 10:35:28 AM

Unsubstantiated

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
04/23/2024 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240423082632

FACILITY NAME:	JRBELLA HOME FOR THE ELDERLY		FACILITY NUMBER:	197610195
ADMINISTRATOR:	TUMALIUAN, NESTOR		FACILITY TYPE:	740
ADDRESS:	17100 CALAHAN STREET		TELEPHONE:	(818) 524-8613
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 4	DATE:	05/14/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Nestor Tumaliuan		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff hit resident
Staff handled resident in a rough manner

INVESTIGATION FINDINGS:

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On 05/14/24, at 9:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Licensee Nestor Tumaliuan. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather additional documentation and deliver findings for this complaint.

On 04/30/24, Licensing Program Analysts (LPAs) Gina Saucedo and Gary Tan initiated the investigation. On 04/30/24, the investigation consisted of four (4) attempted resident interviews and four (4) staff interviews. On 05/14/24, LPA Saucedo conducted a subsequent visit that consisted of obtaining the census, resident, staff roster and additional resident documentation. The licensee Nestor Tumaliuan met with LPA Saucedo to conduct the physical tour at 9:20am.

LIC 9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

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-20240423082632

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: JRBELLA HOME FOR THE ELDERLY	FACILITY NUMBER: 197610195
	VISIT DATE: 05/14/2024

NARRATIVE

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This is an amended copy of the report previously issued on 05/14/2024. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same.

Regarding the allegation: Staff hit resident. It is being alleged that the resident was hit by one (1) of the staff. LPA Saucedo attempted to interview four (4) out of four (4) residents but due to their diagnosis and non-verbal communication, LPA Saucedo did not obtain any information regarding the above allegation. LPA Gary Tan interviewed two (2) staff. S1 and S2 confirmed they were present the day of the allegation and that no staff hit a resident. S1 stated that the above facility belongs to them, and they would not jeopardize it. S2 confirmed that the licensee helps a lot with the residents and the day of the incident, S1 had to help because Resident #1 (R1)’s diaper and mat were wet. LPA Saucedo interviewed two (2) additional staff. S3 and S4, confirm that S1 helps with all the residents. Therefore, based on the LPA's record reviews, staff and resident attempted interviews the above allegation(s) is unsubstantiated at this time.

Regarding the allegation: Staff handled resident in a rough manner. It Is being alleged that the resident was handled inappropriately by staff. LPA Saucedo attempted to interview four (4) out of four (4) residents but due to their diagnosis and non-verbal communication, LPA Saucedo did not obtain any information regarding the above incident. LPA Gary Tan interviewed two (2) staff. S1 & S2 confirmed no resident was handled inappropriately by staff. S2 stated that the day of the incident Resident #1 (R1) needed to be moved from the sofa and they needed help. S1 did state R1 needs a minimum of two (2) people to move R1 and that’s when they helped with R1. It took three (3) staff that day to move R1 from the sofa. The staff continued to say that S1 is gentle with the residents. S3 and S4 confirm that S1 helps with all the residents. Another staff-Staff #5 (S5) that helped R1 move from the sofa that day was interviewed via telephone by LPA Saucedo. Therefore, based on the LPA's record reviews, staff and resident attempted interviews the above allegation(s) above is unsubstantiated at this time.

An exit interview was conducted, no citations were issued for above allegation(s), and a copy of this report was given to the Licensee.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

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