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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600872
Report Date: 09/15/2022
Date Signed: 09/15/2022 10:36:49 AM

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
09/08/2022 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220908100717
FACILITY NAME:A AND M HOME CAREFACILITY NUMBER:
198600872
ADMINISTRATOR:AMALIA FERRERFACILITY TYPE:
735
ADDRESS:2954 KING STREETTELEPHONE:
(909) 618-7065
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:6CENSUS: 6DATE:
09/15/2022
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Mona Dela Rosa - LicenseeTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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9
Staff member used inappropriate language toward client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegation. LPA met with Mona Dela Rosa (Licensee) and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of the client roster, staff roster, and Individual Program Plans (IPPs) for Client 1 – Client 6 (C1 – C6). Interviewed Licensee, Staff 1 – Staff 3 (S1 – S3), and Client 1 – Client 6 (C1 – C6).

The investigation revealed the following: regarding the allegation "staff member used inappropriate language toward client”, it is alleged that a staff cussed at a client and made mean/inappropriate comments about this client’s weight.
(CONTINUED TO LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
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 2
Control Number 28-AS-20220908100717
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: 09/15/2022
NARRATIVE
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Licensee and staff interviewed denied the allegation and stated that clients are treated with dignity and respect. Clients interviewed revealed that 6 out of 6 clients were unable to corroborate the allegation. The client in question changed the story during the interview by stating that it did not happen and that it happened. However, at the end of the interview this client denied the allegation and stated that the staff just made fun of the way the client walks. Review of the IPP for the client in question revealed that this client has a history of making false accusations and sometimes will change the story at a later time.

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 held and a copy of the report was provided
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2