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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600856
Report Date: 05/24/2024
Date Signed: 05/24/2024 04:52:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/20/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240520134918
FACILITY NAME:LARDIZABAL HOMEFACILITY NUMBER:
198600856
ADMINISTRATOR:MARY ANNE NACUAFACILITY TYPE:
735
ADDRESS:212 LONE HILL AVETELEPHONE:
(626) 857-1071
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 4DATE:
05/24/2024
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Mary Ann NacuaTIME COMPLETED:
01:36 PM
ALLEGATION(S):
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Staff did not properly transport resident, resulting in client sustaining an injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 05/24/2024 regarding the above allegations. LPA Ramirez was met by Caregivers Leticia Romero and Lucia Senoron explained the purpose of the visit. Administrator Mary Anne Nacua arrived shortly after to assist with tour.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 3 interviews (S1 – S3), Attempted interview of Client#1 (C1), copies of Client#1 (C1) Physician’s Report dated 06/12/2023, Identification and Emergency Information form, Admission Agreement, Quarterly Progress Report from San Gabriel/ Pomona Regional center dated 03/19/2024, San Gabriel/ Pomona Regional Center Individual Program Plan (IPP) dated 03/27/2024, San Gabriel/Pomona Regional Center Corrective Action Plan (CAP) dated 05/16/2024 and physical plant tour.
SEE 9099-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
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 3
Control Number 28-AS-20240520134918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LARDIZABAL HOME
FACILITY NUMBER: 198600856
VISIT DATE: 05/24/2024
NARRATIVE
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The investigation revealed the following. Regarding Allegation: Staff did not properly transport client, resulting in client sustaining an injury- It is alleged that on 05/05/2024, C1 was sitting in the facility wheelchair and was being wheeled to the dinning room table by S1. As C1 was being wheeled, C1’s right foot got caught under the wheelchair’s right tire. C1 made a sound that alerted S1 and S1 stopped the wheelchair and noticed C1’s foot was caught by the right wheel. S1 immediately did a body check on C1 and did not observe any swelling, bruising, damage to skin or color change was observed. Administrator Nacua was notified by S1 via phone and Administrator Nacua arrived shortly after to assess C1. Administrator Nacua did not observe any swelling, bruising, or damage to skin. On 05/06/2024, Administrator Nacua and staff observed C1’s right ankle swollen and appeared to bruised. Administrator Nacua took C1 to Foothill Presbyterian ER and it was revealed C1 was diagnosed with minimally displaced fracture of the medial malleolus (lowest part of the tibia, or inner bone of the ankle). During LPA’s interviews with staff and client record review, it was revealed that C1 has been residing at the facility since 2007. C1 was accepted into the facility with their own custom-built wheelchair. Per interviews with staff, C1’s custom wheelchair is significantly taller than the facility dining room table. Staff would transport C1 from their custom-built wheelchair to the facility wheelchair so that C1 could enjoy their meals with the rest of the clients. According to staff interviews, staff has been transporting C1 to the dining room table in this manner since C1 arrived at the facility and there has been no prior incidents of C1 receiving injury while being transported in this manner. During facility tour, LPA Ramirez measured the height difference from C1’s custom-built wheelchair and the facility dining room table. LPA Ramirez observed there to be a 1ft difference between the height of C1’s custom-built wheelchair and the facility dining room table. LPA Ramirez measured the height difference between the facility wheelchair and the facility dining room table. The facility wheelchair and dining room table were observed to be at the same height. Although staff has been utilizing the facility wheelchair to transport C1 to the dining room table, C1’s custom-wheelchair has detachable elevating legrests/footplates for C1’s dangling feet. The facility’s wheelchair was not equipped with these legrests/footplates on 05/05/24, which could have prevented C1’s injury. Due to C1 being nonverbal and suffering from cognitive impairments, LPA Ramirez could not able to conduct interview. Based on interviews and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. LPA Ramirez will issue Type A deficiency. LPA Ramirez consulted Administrator Nacua on different wheelchair trays or adjustable wheelchair tables that can be utilized in the future to avoid removing C1 from their custom-built wheelchair when dining at the facility.
One (1) deficiency has been issued during this complaint investigation. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided via email due to printer problems.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240520134918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LARDIZABAL HOME
FACILITY NUMBER: 198600856
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2024
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision
(a) In addition to Section 80078, the following shall apply:(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
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Licensee will use C1's custom built wheelchair according to C1's care plan. Licensee conducted staff re-training on C1's needs and services on 5/20/24. No further action is required. **POC CLEARED DURING VISIT ON 05/24/24. **
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This requirement was not met as evidence by:
Staff did not use C1's custom-built wheelchair when dining at the facility dining room table.
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3