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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198203919
Report Date: 12/13/2021
Date Signed: 12/13/2021 02:37:36 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
07/15/2020 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20200715115251
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:
12/13/2021
UNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Reno SantosTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Resident developed an oral condition due to lack of hygiene care
INVESTIGATION FINDINGS:
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On 12/13/21 Licensing Program Analyst (LPA) Jade Jordan made an unannounced subsequent visit, To continue the investigation initiated on 07/23/20 regarding the allegation above. The LPA was met by Facility Administrator Reno Santos, and the purpose of the visit was explained.

The investigation Included: Physical Plant tour, Record Review, Resident Interviews, Administrator interviews, and observation of Video.

On 11/10/20 Resident (R1)was placed on hospice with agency Providence Trinity Care; For End Stages of Life. The goal of hospice was to provide Palliative Care (Comfort). R1 passed away at the facility 12/09/20 due to diagnosis un-related to allegation.
Prior to admissions, Hospice Notes indicated that R1 had oral problems of dry mouth, and tooth decay. LPA viewed “Plan of Care” set in place by hospice agency dated 11/26/20. The plan indicated that one of the Goals of Home Health Aide, was to Assist with Oral Care, beginning 11/27/20, and its Frequency was noted as P.R.N.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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 2
Control Number 11-AS-20200715115251
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: 12/13/2021
NARRATIVE
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Interviews with Administrator revealed that they help assist all Residents in care with oral hygiene. They assist by brushing residents’ teeth. Administrator Stated that there were times when R1 refused to allow staff to brush teeth but did not complain of pain. Interviews with other residents R2, and R3 stated that staff do help assist with brushing their teeth.

Based on LPA Record Review, Interviews Conducted, and Observation it could not be determined when R1 developed the oral condition. Therefore, the LPA finds that although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2