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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198203919
Report Date: 02/23/2021
Date Signed: 04/05/2021 03:54:51 PM



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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/29/2020 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20200929101628
FACILITY NAME:TLC GUEST HOME IIFACILITY NUMBER:
198203919
ADMINISTRATOR:CASTANEDA, TERESITAFACILITY TYPE:
740
ADDRESS:28024 CALZADA DR.TELEPHONE:
(310) 548-0898
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 4DATE:
02/23/2021
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Administrator Muqeet “MD” Daabhoy TIME COMPLETED:
10:12 AM
ALLEGATION(S):
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Staff restrained resident
INVESTIGATION FINDINGS:
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On 02/23/2021 around 1pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Muqeet “MD” Daabhoy.

The Investigation consisted of the following: On 10/06/2020 LPA Calderon interviewed Administrator Muqeet “MD” Daabhoy (S1) and conducted a tour of the physical plant. LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Admissions Agreement for R1. On 10/05/2020 LPA Calderon interviewed S2-S3. On 09/30/2020 LPA Calderon interviewed Resident #1 Responsible Party and on 10/05/2020 interviewed Ombudsmen. On 10/05/2020 LPA attempted to interview R1 but was unsuccessful due to R1 medical diagnosis there were communication barriers.




Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
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 5
Control Number 11-AS-20200929101628
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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TLC GUEST HOME II
FACILITY NUMBER: 198203919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2021
Section Cited
CCR
87468.1(A)(3)
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87468.1Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse...
This requirement is not met as evidenced by:
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Facility to train all staff regarding personal rights issues and to provide DSS traing sign in sheet
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Based on observations staff did tie down resident to chair who poses an immediate health, safety, or personal rights risk to persons in care.
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CCR
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20200929101628
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TLC GUEST HOME II
FACILITY NUMBER: 198203919
VISIT DATE: 02/23/2021
NARRATIVE
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The investigation revealed the following:

Allegation: Staff restrained resident
It is alleged on 9/4/2020 facility staff tied R1 down to a chair with a belt around the waist which was attached to the chair. On 10/05/2020 LPA Calderon interviewed S2-S3 who both confirm they witnessed R1 tied down to a chair. On 10/06/2020 S1 confirmed staff informed him that R1 had been tied down to a chair to prevent him from wandering. On 10/16/2020 reviewed medical records for R1, there is no doctor’s instruction to restrain R1.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Administrator Muqeet “MD” Daabhoy, and a hard copy was provided via email for records
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/29/2020 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20200929101628

FACILITY NAME:TLC GUEST HOME IIFACILITY NUMBER:
198203919
ADMINISTRATOR:CASTANEDA, TERESITAFACILITY TYPE:
740
ADDRESS:28024 CALZADA DR.TELEPHONE:
(310) 548-0898
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 4DATE:
02/23/2021
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Administrator Muqeet “MD” Daabhoy TIME COMPLETED:
10:12 AM
ALLEGATION(S):
1
2
3
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8
9
Rsident was not issued a refund
Resident was overcharged
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/23/2021 around 1pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Muqeet “MD” Daabhoy.

The Investigation consisted of the following: On 10/06/2020 LPA Calderon interviewed Administrator Muqeet “MD” Daabhoy (S1) and conducted a tour of the physical plant. LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Admissions Agreement for R1. On 10/05/2020 LPA Calderon interviewed S2-S3. On 09/30/2020 LPA Calderon interviewed Resident #1 Responsible Party and on 10/05/2020 interviewed Ombudsmen. On 10/05/2020 LPA attempted to interview R1 but was unsuccessful due to R1 medical diagnosis there were communication barriers.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20200929101628
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TLC GUEST HOME II
FACILITY NUMBER: 198203919
VISIT DATE: 02/23/2021
NARRATIVE
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Allegation: Resident was not issued a refund
It is alleged when R1 was admitted to the facility there was a verbal agreement with Administrator MD that total charges for all services would be $4000.00. R1 Responsible Party stated Administrator accepted $4000.00 for R1 services and a week later R1 son was charged an additional $1500.00 for services. RP states R1 was in facility for 1 month and she removed resident from facility. On 10/09/2020 received and reviewed cashed checks for $4000.00, $1500.00 and $1000.00 made payable to facility. On 10/06/2020 LPA Calderon interviewed Administrator MD who states he charged $5500.00 for private room and $1000.00 for other services and that the admission agreement “page 3” supports total charges of $6500.00. On 10/16/2020 LPA Calderon reviewed admission agreement for R1. Total charges for services total $5500.00 this are from page 4 of agreement. There is documentation to support charges of $6500.00. Administrator states page 3 of agreement part 7 “payment provisions” he claims processing fee of $500.00 and assessment fee of $500.00 were to be charged every month.

Allegation: Resident was overcharged


It is alleged on 9/4/2020 R1 Responsible Party had a verbal agreement with Administrator MD that total charges for all services would be $4000.00. R1 Responsible Party stated Administrator accepted $4000.00 for R1 services and a week later R1 son was charged an additional $1500.00 for services. RP states R1 was in facility for 1 month and she removed resident from facility. On 10/09/2020 received and reviewed cashed checks for $4000.00, $1500.00 and $1000.00 made payable to facility. On 10/06/2020 LPA Calderon interviewed Administrator MD who states he charged $5500.00 for private room and $1000.00 for other services and that the admission agreement “page 3” supports total charges of $6500.00. On 10/16/2020 LPA Calderon reviewed admission agreement for R1. Total charges for services total $5500.00 this are from page 4 of agreement. There is documentation to support charges of $6500.00. Administrator states page 3 of agreement part 7 “payment provisions” he claims processing fee of $500.00 and assessment fee of $500.00 were to be charged every month. 81507 (c) Any fee that is charged prior to or after admission, shall be clearly specified.
Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be unsubstantiated. .

A telephonic exit interview was conducted with Administrator Muqeet “MD” Daabhoy, and a hard copy was provided via email for records
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5