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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204012
Report Date: 06/13/2022
Date Signed: 06/13/2022 06:09:00 PM

Substantiated


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
03/07/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220307103756
FACILITY NAME:ATKINSON CARE HOMEFACILITY NUMBER:
198204012
ADMINISTRATOR:MUQEET D. DADABHOYFACILITY TYPE:
740
ADDRESS:17035 ATKINSON AVENUETELEPHONE:
(310) 819-8218
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: 2DATE:
06/13/2022
UNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Muqeet D. DadabhoyTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility illegaly evicted resident.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Martessa Brown, conducted an unannounced subsequent complaint visit to deliver findings at Atkinson Care Home regarding the above allegation. LPA met with Leo Sumalponng, Caregiver and was later met by administrator and explained the reason for the visit.

During the visit on 3/11/22, LPA toured the home and spoke to assistant administrator. LPA requested the following documents LIC500 resident #1 physician report, appraisals, needs & service, most recent incident reports for R#1 and hospital records be sent by email 3/16/22.

The investigation consisted of the following: On 4/22/22 interview was conducted by LPM Hammond. On 6/11/22 LPA conducted interviews with staff #1-2.

Investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
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 3
Control Number 11-AS-20220307103756
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: ATKINSON CARE HOME
FACILITY NUMBER: 198204012
VISIT DATE: 06/13/2022
NARRATIVE
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Allegation: Facility illegally evicted resident.

LPM Hammond interviewed the administrator regarding the above allegation. Administrator stated R1 would disturb the staff and other residents. He stated had informed the family that R1’s health was having breathing problems and health was declining. He mentioned to the family about putting R1 in a private room for the same rent amount to meet R1’s need. Administrator stated family refused and informed him they were going to move R1 to another facility. Administrator stated resident was having breathing problems again and was transported to the hospital and hospital kept resident. He stated did not evict R1. LPA conducted interviews with staff #1-2 stated r1 was disturbing staff and residents and was having breathing problems at night that seemed like a panic attack. S1 stated called family to inform R1 had several incidents but family did not was R1 to be transported to the hospital. S1 stated in February 2022 R1 had to be transported to the hospital and family was notified. Staff stated while R1 was in the hospital was told R1 will not be returning to the facility. On 6/11/22 LPA reviewed R1’s incident report that stated 911 was call and resident was transported to the hospital. Based on documentation and interviews administrator did not have R1 re-evaluated in order to notify family of r1’s needs.

Based on LPAs observations and interviews which were conducted record review(s), 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.

Exit Interview Conducted, appeal rights were explained, and a copy of this report was furnished. to Leo Caregiver.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220307103756
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: ATKINSON CARE HOME
FACILITY NUMBER: 198204012
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2022
Section Cited
CCR
87224(a)
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87224 Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).
This Requirement was not met as evidence by:

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Licensee will review eviction procedures and will outline a plan on how he will adhere to eviction procedure and re-evaluate residents to reflect Title 22. Licensee will send copy by poc due to LPA M. Browns attention.
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Based on observations and interviews conducted, Licensee did not have R1 re-evaluated to determine if the facility was the appropriate place for resident to continue living in the home.
This is a potential health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3