198600872-8-23-2022-28-AS-MVAO-CJ9M4S-20220914091713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600872
Report Date: 08/23/2022
Date Signed: 08/23/2022 01:41:00 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
11/03/2021 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211103145458

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:	08/23/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	S-1/Mona Dela Rosa		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff hit client on head with shower head.
Staff does not treat client with dignity.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit on 11/08/2021. LPA met with S-1 and discussed the purpose of today's visit.

During this investigation, LPA interviewed S-1 through S-3. LPA interviewed Staff #5 (S-5) and Placement Agency Quality Assurance Representative via telephone. S-4 was unreachable. LPA interviewed Client #1 through Client #3 (C-1 through C-3). LPA was unable to interview Client #4 through Client #5 (C-4 through C-5) as both are non-verbal. LPA also reviewed Client files for Client #1 through Client #3 (C-1 through C-3) and obtained relevant documentation.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

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-20211103145458

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: 08/23/2022

NARRATIVE

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Allegation: Staff hit client on head with shower head. Staff interviews revealed staff do not hit clients on the head with the shower head. Staff interviews revealed that C-2 receives assistance with washing C-2’s hair as C-2’ is unable to complete this task independently and is unable to wet all of C-2’s hair independently. C-2 has thick, curly and tangled hair. Interviewed staff indicated they learned about this incident when C-2’s day program reported it to them. Staff interviews revealed that 10/13/21, during C-2's shower, C-2 received a call from C-2’s friend. Due to C-2 being inside the shower with running water, C-2 was instructed by S-5 to not use the phone since C-2 and the floor were wet. C-2's phone was on top of the bathroom sink counter. Per staff notes, C-2 proceeded to grab the phone and answered the call although S-5 informed C-2 of the danger to stepping out and using the cell phone while wet. During this incident, there was no report alleging S-5 hitting C-2 with the shower head. Staff interviews also revealed there has not been any allegations of this type of incident prior to this incident. In regards to client interviews, (4) out of (6) clients indicated staff do not hit clients on the head with a shower head nor have they witnessed anyone being hit. (2) out of (6) clients were not interviewed as they are non-verbal (C-4 and C-5). Staff interviews, client interviews and reviewed documentation do not corroborate this allegation.

Allegation: Staff does not treat client with dignity. Staff interviews revealed that staff treat clients with dignity and respect. Interviewed staff indicated they have not witnessed any staff not treating clients with dignity and respect. Interviewed staff indicted they have not received any complaints/concerns in regards to staff not treating clients with dignity. Interviewed staff also indicated they are trained in mandated reporting, client rights and zero tolerance. In regards to client interviews, (4) out of (6) clients indicated staff treat clients with dignity and respect. (2) out of (6) clients were not interviewed as they are non-verbal (C-4 and C-5). Staff interviews and client interviews do not corroborate this allegation.

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 conducted, a copy of this report and appeal rights were provided to Mona Dela Rosa.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC9099 (FAS) - (06/04)

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