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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600640
Report Date: 09/26/2024
Date Signed: 09/26/2024 05:14:35 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 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
02/02/2023 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230202100121
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL ROSEMEADFACILITY NUMBER:
198600640
ADMINISTRATOR:MOHAMMED SHIRAZIFACILITY TYPE:
735
ADDRESS:1702 ROBIN LINDA LNTELEPHONE:
(626) 927-9177
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:4CENSUS: 4DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Justin Johnson, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff neglect resulted in resident falling and sustaining injuries.
Facility staff did not seek timely medical attention for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations. The investigation was completed by DSS/CCLD Investigations Branch (IB) Investigator Laura Garcia, badge # 255. The purpose of the visit was explained telephonically to Administrator Justin Johnson. DSP staff Anabel Cruz signed the report.

The investigation consisted of: On 2/2/2023, a 24-hour visit to check the health and safety of residents was conducted. LPA reviewed R1's file and obtained the following documents: [Identification and Emergency Information, Admission Agreement, Regional Center Placement documents, Physician's Report, Resident Appraisal, Physician's Orders, Appraisal /Needs and Services Plan, Individual Service Plan, Centrally Stored Medication Record/Medication Administration Recors (Jan. 2023- Feb. 2023), 2 incident reports dated 1/27/23 & 1/30/23, Consumer Mark and Bruise Documentation Sheet, LIC 500 Personnel Report, and Register of Facility Residents. No health and safety concerns were observed at the time of the visit. During today's visit, no health and safety issues were observed.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 28-AS-20230202100121
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: KAISER SPECIALIZED RESIDENTIAL ROSEMEAD
FACILITY NUMBER: 198600640
VISIT DATE: 09/26/2024
NARRATIVE
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Allegation: Facility staff neglect resulted in resident falling and sustaining injuries. It is alleged that resident (R1) was taken to the Emergency room of the San Gabriel Valley Medical Center on Monday 1/30/23 with a black eye (right eye), a skin tear on the right elbow and bruising on the left arm. DSS Investigator Laura Garcia obtained medical records and conducted interviews with facility staff, R1's conservator, medical doctors, and Regional Center staff. Facility and medical records were reviewed and obtained. Medical records and statements verified that R1 sustained multiple injuries as a result of the witnessed fall (1/27/23), in which the resident hit their head and had apparent bruising on the head and arm. The administrator admitted that the incident was not reported to ELARC, CCL and Long-Term Ombudsman. Additionally, the Eastern Los Angeles, Regional Center (ELARC) applied sanctions to the facility due to two findings of “Substantial” inadequacies. Based on the above information, there is sufficient evidence to support the allegation of neglect/ lack of care by the Kaiser Specialized Residential Rosemead staff.

Allegation: Facility staff did not seek timely medical attention for resident. It was reported that on 1/27/2023, facility staff reported to Administrator Mohammed Raymond Shirazi that staff witnessed resident (R1) fall in the dining the room, but staff did not seek medical attention until they noticed bruising developing on the resident's face above the right eye on Monday 1/30/2023. DSS Investigator Laura Garcia obtained medical records and conducted interviews. Statements provided by facility staff, confirmed that on the day of the incident, resident (R1) was only assessed and offered a cold compress to the resident’s head injury. No medical attention was immediately sought out to ensure that the resident did not require further medical attention and ensure R1 did not suffer a concussion. The ELARC Regional Center issued the facility a corrective action plan for failure to seek appropriate medical care. Based on the above information, there is sufficient evidence to corroborate the allegation.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22. See LIC 9099D.

Exit interview conducted with Annabel Cruz. A copy of the report, civil penalty, and appeal rights were issued via email due to printer issues. A hard copy of the report will be mailed.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230202100121
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: KAISER SPECIALIZED RESIDENTIAL ROSEMEAD
FACILITY NUMBER: 198600640
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2024
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met evidenced by:
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Administrator agrees to submit a written plan of correction that includes:
1. Facility fall /emergency protocols/procedures.
2. In-service training log of all staff
3. Body check documentation
4. Reporting requirements training
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Based on interviews and record review, the findings indicate that on 1/27/23, R1 sustained multiple injuries [black eye (right eye), a skin tear on the right elbow and bruising on the left arm] after falling in the presence of staff, which posed an immediate health and safety risk.
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Type A
10/10/2024
Section Cited
CCR
80072(a)(9)
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Personal Rights. Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To receive or reject medical care, or health-related services, except for minors and other clients for whom a guardian, conservator, or other legal authority has been appointed.
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Administrator agrees to:
1. Conduct fall risk training and emergency response.
2. Submit a copy of the staff in-service training, which includes training topics/regulation reference.
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This requirement was not met evidenced by:
Based on investigation findings, record review, and interviews it was confirmed that no medical attention was immediately sought out to ensure that R1 did not require further medical attention after the fall incident on 1/27/23, which posed an immediate health and safety risk.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/02/2023 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230202100121

FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL ROSEMEADFACILITY NUMBER:
198600640
ADMINISTRATOR:MOHAMMED SHIRAZIFACILITY TYPE:
735
ADDRESS:1702 ROBIN LINDA LNTELEPHONE:
(626) 927-9177
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:4CENSUS: 4DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Justin Johnson, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff did not prevent resident from using felony drugs in the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegation. The investigation was completed by DSS/CCLD Investigations Branch (IB) Investigator Laura Garcia, badge # 255. The purpose of the visit was explained was explained telephonically to Administrator Justin Johnson. DSP staff Anabel Cruz signed the report.

The investigation consisted of: On 2/2/2023, a 24-hour visit to check the health and safety of residents was conducted. LPA reviewed R1's file and obtained the following documents: [Identification and Emergency Information, Admission Agreement, Regional Center Placement documents, Physician's Report, Resident Appraisal, Physician's Orders, Appraisal /Needs and Services Plan, Individual Service Plan, Centrally Stored Medication Record/Medication Administration Recors (Jan. 2023- Feb. 2023), 2 incident reports dated 1/27/23 & 1/30/23, Consumer Mark and Bruise Documentation Sheet, LIC 500 Personnel Report, and Register of Facility Residents. No health and safety concerns were observed at the time of the visit.

*Narrative continues next page.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230202100121
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: KAISER SPECIALIZED RESIDENTIAL ROSEMEAD
FACILITY NUMBER: 198600640
VISIT DATE: 09/26/2024
NARRATIVE
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Allegation: Facility staff did not prevent resident from using felony drugs in the facility. It is alleged that on January 30, 2023, resident (R1) was taken to the hospital and test results came back positive for cocaine in the resident's system. DSS Investigator Laura Garcia obtained medical records and conducted interviews with facility staff, R1's conservator, medical doctors, and Regional Center staff. Based on record review, the findings indicate that R1initially tested positive for three controlled substances; benzo, opiates, and cocaine. Three days later, R1 was retested, and the hospital lab results continued a positive test for benzo and opiates. However, cocaine returned with a negative result. Investigator interviewed Medical Doctor and Pathology Department Medical Director regarding the test results, their professional opinion was that there was no definitive explanation for how the resident’s initial positive test result for cocaine. According to R1's primary physician, a review of the resident’s medical history and prescribed medication could possibly provide an explanation for the test results. Based on the information provided, there is insufficient evidence to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted with DSP Annabel Cruz. A copy of the report was issued electronically due to printer issues. A hard copy of the report will be mailed.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5