198204800-2-12-2025-11-AS-SCIS-DHH2DC-20250609171801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204800
Report Date: 02/12/2025
Date Signed: 02/12/2025 03:06:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2025 and conducted by Evaluator Troy Watson

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250203171330

FACILITY NAME:	MY MOTHER'S PLACE		FACILITY NUMBER:	198204800
ADMINISTRATOR:	HILDA LOZANO		FACILITY TYPE:	740
ADDRESS:	11827 ROSE AVENUE		TELEPHONE:	(310) 707-7768
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	6	CENSUS: 5	DATE:	02/12/2025
		UNANNOUNCED	TIME BEGAN:	10:44 AM
MET WITH:	Hilda Lozano - Administrator		TIME COMPLETED:	03:08 PM

ALLEGATION(S):

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Staff did not dispense medication to resident as prescribed by physician.

INVESTIGATION FINDINGS:

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On 02/12/2025, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced complaint investigation at the facility listed above. LPA Watson arrived at the facility and was greeted by the administrator Hilda Lozano. LPA Watson explained the purpose of the visit was to investigate the allegation listed above and was granted entry into the facility.

The investigation consisted of the following:

CONTINUED ON LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (424) 544-1088
LICENSING EVALUATOR NAME: Troy Watson	TELEPHONE: (424) 544-1069
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

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 11-AS-20250203171330

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MY MOTHER'S PLACE	FACILITY NUMBER: 198204800
	VISIT DATE: 02/12/2025

NARRATIVE

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On 02/12/2025 the department interviewed the Administrator and requested and received the following documents: Physicians Order Medimark II, Register of Facility Client/Residents Roster LIC9020, and Staff Roster Personnel Report LIC500. On 02/12/2025 the Department interviewed staff #1-Staff#4 and interviewed residents #1-#4, and attempt to interview resident #5 was made, but it was found the (R5) was non-verbal.

The investigation revealed the following:

Allegation: Staff did not dispense medication to resident as prescribed by physician.
On 02/12/2025 the department conducted interviews with staff#1 – staff #4 (S1-S4). The department asked the staff, do you dispense medication to resident as prescribed by the physician? Of those interviewed, 4 out of 4 staff answered no. On 02/12/2025 the department interviewed residents 1 – residents 4 (R1-R4). The department attempted to interview resident #5, but (R5) was non-verbal. The department asked residents, do the staff dispense medication as prescribed by your physician? Of those interviewed, 4 out 4 residents answered no. Based on the information gathered, there is insufficient evidence to support the stated allegation.

After reviewing the medication records for resident#1 (R1) it was revealed that medication for (R1) is administered 3 times a week as prescribed by the physician. A blood test taken by Kaiser Cadillac for R1 was conducted and it was verified that the level of medication administered to R1 was normal.
Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to the assistant administrator Hilda Lozano.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (424) 544-1088
LICENSING EVALUATOR NAME: Troy Watson	TELEPHONE: (424) 544-1069
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC9099 (FAS) - (06/04)

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