197800744-7-14-2022-28-AS-LHIS-CK6T6F-20221013142702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197800744
Report Date: 07/14/2022
Date Signed: 07/14/2022 02:29:38 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220318101718

FACILITY NAME:	CASITAS ESPERANZA		FACILITY NUMBER:	197800744
ADMINISTRATOR:	JOSE GOMEZ		FACILITY TYPE:	772
ADDRESS:	11925 1/4,1/2 11931 ELLIOTT AV		TELEPHONE:	(626) 350-5304
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91732
CAPACITY:	13	CENSUS: 12	DATE:	07/14/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Shannon Steib, Administrator		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Staff do not ensure client is accorded safe, healthful, and comfortable accommodations.
Staff are not ensuring incontinent client is kept clean.
Staff are not ensuring facility is kept clean.
Staff are not ensuring facility remains odor free.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations.The purpose of the visit was discussed with Administrator Shannon Steib.

The investigation consisted of: On 3/23/2022, a physical plant inspection of the facility grounds and rooms 7 & 8 was completed. Staff (S1-S4) and clients (C1-C5) were interviewed. LPA reviewed and obtained the following documents: Client Identification/Emergency Contact, Pre-Placement Assessment, Physician’s Report, Admission Agreement, 30-day eviction notice [3/16/22], 2 incident reports dated [3/16/22 & 3/21/22], hospital reports, client roster, and LIC 500 Personnel Report.

During today's visit, staff (S1, S5, & S6) were interviewed, and additional documents pertaining to C1 were obtained [Weekly Summary notes, Plan of Operation, Discharge Summary, Individual Therapy Notes, Residential Program Client Handbook, and incident reports dated 3/8/2022 & 4/21/2022.
See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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 28-AS-20220318101718

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASITAS ESPERANZA	FACILITY NUMBER: 197800744
	VISIT DATE: 07/14/2022

NARRATIVE

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Allegation: Staff do not ensure client is accorded safe, healthful, and comfortable accommodations. It is alleged client (C1) in room 8 was defecating and urinating in it's room, bathroom, and on the walls. The other client living in the room had to frequently leave so that staff could assist C1 with cleaning. As a result, C1 was moved to room 7 and isolated to protect other clients. The psychosocial rehabilitation treatment program is designed to stabilize and/or increase independent living skills. Clients are expected to maintain their hygiene, cleanliness of their room, wash their own linens/clothing, perform their own ADLs, shower daily, and keep room free of odors. Clients have assigned chores; of which C1 was not performing. Staff provided C1 clorox wipes, Febreze, and prompted the resident to clean room, wash bedding linens, and maintain hygiene. LPA conducted a physical plant inspection of C1's room (7) and room 8 no unhealthful or uncomfortable accommodations were observed. Client (C1) stated it is provided safe and healthful accommodations, and that staff conduct frequent checks, assist with bedding sheet changes, ensure the room does not smell, and have sprayed deodorizer in the rooms. One (1) out of five (5) clients interviewed reported issues with accommodations related to C1's incontinence issues, but stated staff were trying their best to encourage C1 to use the bathroom and maintain hygiene. All staff stated clients are expected to do their own chores, clean their room, do own laundry, and take out the trash. Staff were assisting C1 in order to maintain comfortable accommodations for C1 and other clients living in the room .

Allegation: Staff are not ensuring incontinent client is kept clean. Based on record review and interviews conducted the findings indicate that the facility is a psychosocial rehabilitation treatment program designed to stabilize and/or increase independent living skills of clients in care. Staff do not provide incontinence care. They prompt clients to use the bathroom and maintain proper hygiene. It is alleged that C1 was defecating on self. Staff interviewed stated C1 was prompted every 30 minutes to go to the bathroom and clean self. The facility purchased sheets, clothing, and a new mattress. C1 refused to shower after bowel movements and would lay in bed soiled. Per Physician Report (1/28/222), C1 had the capacity for self care, and did not require toileting assistance. The facility completed an Appraisal on 3/2/2022, and noted decompensating of as evidenced by self-neglect and refusing to use bathroom for toileting needs. Facility staff contacted DMH, PET teams due to C1's self-neglect behavioral issues. However, C1 did not meet psychiatric hold criteria. Staff continued to prompt C1 with incontinence care, but the client refused. Multiple incident reports were addressed with Mental Health agencies and CCL regarding this issue. All clients interviewed stated staff provided assistance and prompting to C1, despite the facility not normally offering incontinence service care for independent clients in care. Staff do not provide bathing assistance.

See LIC 9099C

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220318101718

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASITAS ESPERANZA	FACILITY NUMBER: 197800744
	VISIT DATE: 07/14/2022

NARRATIVE

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Allegation: Staff are not ensuring facility is kept clean. Based on interviews conducted and observation the findings indicate the facility is kept clean and in good repair by staff. It is alleged that room 8 was not kept clean due to C1's frequent incontinence issues, and it's refusal to clean up after self. Staff stated that the staff assisted C1 with cleaning of soiled bedding and floors as needed, even though that is not a staff responsibility under their program design. All clients interviewed denied this allegation and stated staff and clients maintain a clean environment. Staff stated the facility is kept clean and clients are assigned chores. In instances where clients are not able to clean their own room staff are responsible for ensuring it is clean. During the visit, LPA did not observe any uncleanliness of rooms.

Allegation: Staff are not ensuring facility remains odor free. It is alleged that C1's room had a strong smell of feces and urine due to incontinence issues and bathroom toilet issues. The findings indicate that C1 refused to get up to shower after defecating on self. Staff prompted C1 to wash linens, shower, and clean the soiled areas of the room, but the client refused. Staff assisted by bringing Clorox wipes and Febreze to C1 for use. All clients interviewed stated the facility provided C1 products to assist with odors, and did frequent room checks to ensure odors were addressed. All staff denied this allegation, and stated clients are provided cleaning products and assisted if needed.

Although the allegation(s) may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED.

An exit interview was conducted with Administrator Shannon Steib. A copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

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