198600872-8-2-2024-28-AS-TVAO-D7VMYF-20240806100126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600872
Report Date: 08/02/2024
Date Signed: 08/02/2024 10:01:33 AM

Unsubstantiated

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
06/18/2024 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240618103951

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: 5	DATE:	08/02/2024
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Administrator Mona DeLaRosa		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff hit resident multiple times.
Staff did not assist in helping resident after multiple falls.
Staff did not notify residents representatives of incidents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit 08/02/2024 to deliver findings regarding the above allegations. LPA Ramirez was met by Administrator Mona DeLaRosa and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 3 interviews (S1 – S3), Interview of Clients#2-3 (C2-C3), attempted interview of clients#1,4,5 &6 (C1, C4, C5,C6) copies of Client#1 (C1) Physician’s Report , Identification and Emergency Information form for (C1-C6), Admission Agreement for (C1), San Gabriel/ Pomona Regional Center Individual Program Plan (IPP) for (C1), copies of personnel record for (S2-S3) and physical plant tour.

See 9099-C

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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-20240618103951

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: A AND M HOME CARE	FACILITY NUMBER: 198600872
	VISIT DATE: 08/02/2024

NARRATIVE

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The investigation revealed the following. Regarding Allegation(s): Staff hit resident multiple times- It is alleged staff hit C1 multiple times. Three (3) out of the three (3) staff deny this allegation. Two (2) out of the two (2) clients interviewed deny this allegation. Due to two (2) out of the six (6) clients being non-verbal and lacking cognitive abilities, LPA Ramirez was unable to interview clients. C4 declined to be interviewed. Since June 2024, C1 relocated from the facility and was unable to be interviewed. LPA Ramirez attempted to contact C1’s responsible party, but request for a callback was not met. LPA Ramirez reviewed C1 file and did not observe any documenting C1 required medical attention for unexplained injuries. LPA Ramirez reviewed C1’s IPP and it revealed C1 has a history of making false accusations. Although the allegation 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.

Staff did not assist in helping resident after multiple falls- It is alleged staff would not assist C1 when C1 would have a fall. Three (3) out of the three (3) staff deny this allegation. Interviews with staff revealed C1, had difficulty walking and would sometimes lose a step but denied C1 would have constant falls. Two (2) out of the two (2) clients interviewed deny this allegation. Due to two (2) out of the six (6) clients being non-verbal and lacking cognitive abilities, LPA Ramirez was unable to interview clients. C4 declined to be interviewed. Since June 2024, C1 relocated from the facility and was unable to be interviewed. LPA Ramirez attempted to contact C1’s responsible party, but request for a callback was not met. During records reviewed, LPA Ramirez did not observe documentation that indicated C1 received medical attention for multiple falls from April 2024 through June 2024. Although the allegation 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.

Staff did not notify residents representatives of incidents- It is alleged staff did not notify C1’s representatives about C1’s falls. Three (3) out of the three (3) staff deny this allegation. Interviews with staff revealed C1, had difficulty walking and would sometimes lose a step but denied C1 would have constant falls. Two (2) out of the two (2) clients interviewed deny this allegation. Due to two (2) out of the six (6) clients being non-verbal and lacking cognitive abilities, LPA Ramirez was unable to interview clients. C4 declined to be interviewed. Since June 2024, C1 relocated from the facility and was unable to be interviewed. LPA Ramirez attempted to contact C1’s responsible party, but request for a callback was not met. According to staff interviews, staff would notify C1’s responsible party via telephone whenever C1 received medical attention or was feeling ill. Although the allegation 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.

No deficiencies were cited during this investigation complaint. Exit interview was conducted. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC9099 (FAS) - (06/04)

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