198600290-2-2-2022-28-AS-MVAO-CCSTLJ-20220323144938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600290
Report Date: 02/02/2022
Date Signed: 02/02/2022 01:55:37 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2020 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201217085259

FACILITY NAME:	ASUNCION BOARD & CARE		FACILITY NUMBER:	198600290
ADMINISTRATOR:	ROSEMARIE A. ZIMMER		FACILITY TYPE:	740
ADDRESS:	1636 S. RAMA DRIVE		TELEPHONE:	(626) 338-0772
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	6	CENSUS: 4	DATE:	02/02/2022
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Adelaida Asuncion; Licensee		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff unlawfully evicted a resident while in care.
Staff did not follow admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegations. LPA met with Licensee Adelaida Asuncion and explained the reason for the visit.

The investigation consisted of the following: during the initial televisit conducted on 12/18/20, LPA interviewed the Licensee and obtained copies of Resident & Staff Rosters and documents pertaining to Former Resident #1 (FR1). On 07/29/21, LPA interviewed the Licensee and Administrator and reviewed Former Resident #1's (FR1) file. LPA obtained copies of FR1's Preplacement Appraisal, Resident Appraisal, Application/Admission Policies, and Admission Agreement. LPA was unable to interview FR1 during the course of the investigation as FR1 was no longer a resident of the facility.

The investigation revealed the following: "staff unlawfully evicted a resident while in care", it is alleged that FR1 was evicted after only 8 days at the facility. Facility allegedly indicated that they could no longer care for FR1 because she needed stronger medication. FR1 was a resident of the facility from 03/08/20 until 03/15/20.

(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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 28-AS-20201217085259

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ASUNCION BOARD & CARE	FACILITY NUMBER: 198600290
	VISIT DATE: 02/02/2022

NARRATIVE

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Licensee and Administrator indicated that FR1 was not evicted, rather FR1 and FR1's Authorized Representative decided to move FR1 out of the facility voluntarily. An Eviction Notice was never issued by the facility. LPA obtained copy of note dated 03/15/20 which is signed by FR1's Authorized Representative indicating that FR1, her belongings, and medications were going home with her. LPA attempted to contact FR1 and FR1's Authorized Representative multiple times during the course of the investigation, however calls were not returned. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "staff did not follow admission agreement", it is alleged that facility failed to adhere to FR1's admission agreement. LPA reviewed admission agreement for FR1 dated 03/08/20 which was signed by FR1, FR1's Authorized Representative, and Facility Representative. Upon review of FR1's Admission Agreement, it was determined that the Admission Agreement meets all of the elements required under Title 22 Regulations related to Admission Agreements. There was no evidence found to indicate that the Admissions Agreement was not being followed by the facility while FR1 was a resident of the facility. The Application/Processing Fee was not refunded as it did not meet the conditions for refund as indicated in the agreement. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

LIC9099 (FAS) - (06/04)

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