198600872-11-16-2021-28-AS-WSHO-C9Q2N2-20211214163202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600872
Report Date: 11/16/2021
Date Signed: 11/16/2021 02:54:54 PM

Unsubstantiated

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
01/31/2020 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200131152251

FACILITY NAME:	A AND M HOME CARE		FACILITY NUMBER:	198600872
ADMINISTRATOR:	AMALIA FERRER		FACILITY TYPE:	735
ADDRESS:	2954 KING STREET		TELEPHONE:	(909) 618-7065
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 6	DATE:	11/16/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Assistant Administrator / LadyRoxanne Arcibal Administrator / Monaliza DeLa Rosa		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff caused injury to client.

Staff made inappropriate comments to client.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegations of "Staff caused injury to client and Staff made inappropriate comments to client". Upon arriving at the facility, LPA met with Assistant Administrator / LadyRoxanne Arcibal and was later joined by the Administrator / Monaliza DeLa Rosa who assisted with the visit.

LPA Katrdzhyan conducted the initial visit to this facility on 2/5/20, in reference to the allegations listed above. During the course of the investigation, LPA conducted interviews of various persons to include the Administrator, Staff members 1 and 2 (S1 and S2) and Clients 1 through 4 (C1 - C4). LPA was unable to interview Clients 5 and 6 (C5 and C6) as C5 and C6 were not at the facility at the time of visits. LPA also obtained a copy of the investigation report conducted by San Gabriel/Pomona Regional Center (SGPRC) in reference to the allegation of "Staff caused injury to client".
(Please see LIC 9099C for additional information)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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-20200131152251

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: A AND M HOME CARE	FACILITY NUMBER: 198600872
	VISIT DATE: 11/16/2021

NARRATIVE

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Allegation: Staff caused injury to client. The details of this allegation stated that C1 was in the kitchen getting a snack when S1 grabbed C1 by her shirt and yanked her out of the kitchen causing a scratch on her neck. Date and time of incident are unknown.
Based on interviews conducted, there were no witnesses to the alleged incident. During the interview with C1, C1 denied being grabbed by her shirt and getting yanked out of the kitchen by S1, while getting a snack from the kitchen. C1 stated that the scratch on her neck was a result of her accidentally scratching herself while in the shower, due to having long nails. Statements were also obtained from C1 by Quality Assurance Specialist / Michele Daniel from SGPRC and also by the La Verne Police Department and C1's statement were consistent and detailed that C1 obtained the scratch on her neck as a result of accidentally scratching herself while in the shower. SGPRC conducted an investigation on the above mentioned allegation and the findings were Unsubstantiated. According to the Administrator, the La Verne Police Department also did not find any concerns as a result of their investigation. Based on interviews conducted, there is insufficient evidence to support the allegation of "Staff caused injury to client".

Allegation: Staff made inappropriate comments to client. The details of this allegation stated that S1 has cursed at C1, S1 has told C1 to "go to hell" and "get the hell out of my kitchen" and has "flipped her off". Also, S2 has told C1 to "shut the hell up".
During the interview with C1, the statements obtained were inconsistent and changed during the course of the interview. Interviews conducted of S1 and S2 denied being verbally abusive towards C1 or any other client at the facility. Based on majority of the interviews conducted, the statements obtained did not corroborate with the alleged allegation. According to the Administrator, S1 and S2 do not have prior write ups or disciplinary actions against them for being verbally abusive towards clients. Based on interviews conducted, there is insufficient evidence to support the allegation of "Staff made inappropriate comments to client".

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.

An exit interview was conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC9099 (FAS) - (06/04)

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