198320030-1-30-2025-11-AS-RORN-DE3UCJ-20250220142801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320030
Report Date: 01/30/2025
Date Signed: 01/30/2025 02:55:03 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
01/29/2025 and conducted by Evaluator Alfonso Iniguez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250129143926

FACILITY NAME:	TRUE BEGINNINGS		FACILITY NUMBER:	198320030
ADMINISTRATOR:	TILLMAN, LAMAR & AMELA		FACILITY TYPE:	735
ADDRESS:	3138 W 59TH STREET		TELEPHONE:	(310) 270-8172
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90043
CAPACITY:	4; 4	CENSUS: 3	DATE:	01/30/2025
		UNANNOUNCED	TIME BEGAN:	08:24 AM
MET WITH:	Lamar Tillman/License		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff overmedicated a client while in care.
Staff mishandled a client's medication.
Staff have inadequate record keeping for a client.

INVESTIGATION FINDINGS:

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On 1/30/2025 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Lamar Tillman /Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Client’s interviews (C#1-C#3) and Witness interview(W#1). LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, (C#1-C#2) Physicians Report for Residential Care Facilities for the Elderly, (C#1-C#2), (C#1’s) Medication Administration Record (MAR) for 2022,2023,2024 and 2025 and (C#1)’s IPP from South Central Los Angeles Regional Center, (C#1)’s Prescribed Drug History and (C#1)’s Admissions Agreement.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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-20250129143926

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: TRUE BEGINNINGS	FACILITY NUMBER: 198320030
	VISIT DATE: 01/30/2025

NARRATIVE

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Investigation Revealed the Following:

Allegation: Staff overmedicated a client while in care.

The details of the complaint alleged that facility staff is overmedicating (C#1).

During the records review, LPA observed (C#1)'s Physician's Report for Community Care Facilities or LIC 602. LPA noted that (C#1) is not confused; they can follow instructions and communicate effectively. Additionally, LPA reviewed (C#1)'s prescription history, which indicates that (C#1)'s Primary Care Physician ordered Levetiracetam 1000 mg to be taken as one tablet by mouth twice a day on April 11, 2022. The physician then reduced the dosage to 750 mg on July 22, 2022. (C#1) was admitted to the facility on July 25, 2022.

During an Interview with the Administrator (A#1), he stated that the facility staff follows the doctor's orders regarding the clients' prescribed medications and has never overmedicated (C#1) and other clients in care.

During interviews with clients (C#1-C#3), (2) out of (3) stated that they take prescribed medications and when they take their medications, facility staff always tell them what they are taking. In addition, (2) out of (3) clients in care who take prescribed medication stated that the facility staff has never overmedicated them.

During interviews with staff (S#1-S#2), (2) out (2) stated that they follow doctor's orders on clients' prescribed medications, and they have never overmedicated a client in care.

During interviews with Witness #1 (W#1), they stated that during their last visit, (C#1) had never expressed any concerns regarding their medication intake or any mishandling of medications by the facility staff.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20250129143926

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: TRUE BEGINNINGS	FACILITY NUMBER: 198320030
	VISIT DATE: 01/30/2025

NARRATIVE

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Allegation: Staff mishandled a client's medication.

The details of the complaint alleged that facility staff is mishandling (C#1).

During the records review, LPA Iniguez reviewed (C#1)’s latest Individual Program Plan (IPP) dated 3/28/24. It is written that (C#1) is currently in stable health. No hospitalizations or emergency room visitations were reported within the last 12 months. (C#1) continues to receive regular monitoring and checkups for his prescribed medication to assist them with seizure management.

During an Interview with the Administrator (A#1), he stated that the facility staff has never mishandled (C#1)’s medications or another client in care.

During interviews with clients (C#1-C#3), (2) out of (3) stated that the facility staff have never mishandled their prescribed medications.

During interviews with staff (S#1-S#2), (2) out (2) stated that they have never mishandled (C#1)’s medications or other client in care.

During an interview with Witness #1 (W#1), they stated that during their last visit, (C#1) never expressed any concerns regarding their medication intake or any mishandling of medications by the facility staff.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20250129143926

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: TRUE BEGINNINGS	FACILITY NUMBER: 198320030
	VISIT DATE: 01/30/2025

NARRATIVE

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Allegation: Staff have inadequate record keeping for a client.

The details of the complaint alleged that facility staff have an inadequate medication record for clients in care.

During the records review, LPA Iniguez examined the Medication Administration Records (MARs) for (C#1 and C#2) from July 2022 to January 2025. LPA noted a dose change for Levetiracetam from 500 mg to 750 mg in August 2022, documented in (C#1)’s MARs. Furthermore, from August 2022 to January 2025, facility staff consistently followed and accurately documented (C#1 and C#2) prescribed medication regimen. LPA Iniguez found no discrepancies in (C#1 and C#2)’s Medication Administration Records. In addition, LPA was observed in the prescribed medication bottle (C#1); it is written that the current dose is 750mg twice a day.

During an Interview with the Administrator (A#1), he stated that the facility staff keeps accurate documentation on (C#1 and C#2)’s prescribed medications.

During interviews with clients (C#1-C#3), (3) out of (3) stated that they think the facility is doing a good job documenting the medications given to them.

During interviews with staff (S#1-S#2), (2) out (2) stated that the facility is keeping an adequate record of (C#1 and C#2) Medication Administration Records-MARS

During an interview with Witness #1 (W#1), they stated that during their visits to the facility, they had not observed any discrepancies in (C#1)’s Medication Administration Records (MARs).

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20250129143926

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: TRUE BEGINNINGS	FACILITY NUMBER: 198320030
	VISIT DATE: 01/30/2025

NARRATIVE

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During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the Complaint Report was given to Lamar Tillman /License.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

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