198600872-6-16-2025-28-AS-LHIS-DKFRPG-20250811131156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600872
Report Date: 06/16/2025
Date Signed: 06/16/2025 03:28:20 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
06/13/2025 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250613152020

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:	06/16/2025
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Mona De La Rosa - Licensee / Administrator		TIME COMPLETED:	03:46 PM

ALLEGATION(S):

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Facility staff pulled resident's ear

INVESTIGATION FINDINGS:

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Licensing Proram Analyst (LPA) Erik Zaragoza conducted an unannounced initial complaint visit to investigate the allegation listed above. LPA met with Mona De La Rosa, licensee and administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: LPA obtained copies of the staff and client rosters, interviewed Staff #1 - 5 (S1 - S5), interviewed Witness #1 (W1), interviewed Clients #1 - 5 (C1 - C5), and obtained the Individual Program Plan (IPP), Physician's Report, and FACE Sheet for C1. LPA attempted to interview Client #6 (C6) however they were not present in the facility to be interviewed.

The investigation revealed the following: In regards to the allegation that "Facility staff pulled resident's ear," it is alleged that S2 had pulled on the ear of C1 on 6/12/2025 after they had asked if they could stay up late.

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

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 5

Control Number 28-AS-20250613152020

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: 06/16/2025

NARRATIVE

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During interviews with the clients, three (3) out of five (5) interviewed corroborated the allegation. One of the clients interviewed stated that they did witness S2 perform a small tug on the ear of C1 the previous week in order to get C1 to listen to them. During an interview with another client they stated that they have witnessed S2 has gotten mad at C1 and has yelled at them in the past. During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed stated that they had just become aware of the incident last Friday 6/13/2025 and had never witnessed S2 be pull the ear or physically touch C1 or any of the clients before. Another staff member interviewed stated that they have never witnessed S2 act aggressively towards any of the other clients in the facility in the past. During record review it does not detail that C1 has any history of fabrication in the past.

Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 1 is being cited on the attached LIC9099D.

Exit interview was held and a copy of the report along with the appeal rights were provided and will be emailed to the administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
06/13/2025 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250613152020

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:	06/16/2025
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Mona De La Rosa - Licensee / Administrator		TIME COMPLETED:	03:46 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff hit resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Proram Analyst (LPA) Erik Zaragoza conducted an unannounced initial complaint visit to investigate the allegation listed above. LPA met with Mona De La Rosa, licensee and administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: LPA obtained copies of the staff and client rosters, interviewed Staff #1 - 5 (S1 - S5), interviewed Witness #1 (W1), interviewed Clients #1 - 5 (C1 - C5), and obtained the Individual Program Plan (IPP), Physician's Report, and FACE Sheet for C1. LPA attempted to interview Client #6 (C6) however they were not present in the facility to be interviewed.

The investigation revealed the following: In regards to the allegation that "Facility staff hit resident," it is alleged that S3 had hit C1 on the top of their head on 6/11/2025 after they attempted to swap the pudding they had been given for another one.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20250613152020

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: 06/16/2025

NARRATIVE

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During interviews with the clients, four (4) out of five (5) interviewed did not corroborate the allegation. One of the clients interviewed stated that they have never witnessed S3 hit or touch C1 in the past nor any of the other clients. Another client interviewed similarly stated that they have never observed S3 hit C1 in the past. During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed stated that they have never witnessed S3 hit or touch C1 inappropriately in an attempt to hur them in the past. Another staff interviewed also stated that they have never witnessed anything like S3 hitting C1 or any of the other clients in the past.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 held, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20250613152020

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/17/2025 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse (...) or aids to physical functioning.	1 2 3 4 5 6 7	Administrator is to ensure that all clients are free from unusual punishment and infliction of pain at all times. Administrator is to create a plan for personal rights training amongst staff and email the plan to the LPA by the POC due date.
	8 9 10 11 12 13 14	This regulation is not met as evidenced by: Based on interviews, LPA determined that S2 had pulled on the ear of C1 last week in an attempt to force C1 to listen to them, which poses an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC9099 (FAS) - (06/04)

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