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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600948
Report Date: 10/17/2022
Date Signed: 10/17/2022 02:08:19 PM

Substantiated


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
10/10/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221010151359
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL FAIRVIEWFACILITY NUMBER:
198600948
ADMINISTRATOR:SERGIO CALDERONFACILITY TYPE:
735
ADDRESS:114 FAIRVIEW AVETELEPHONE:
(626) 576-0477
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:4CENSUS: 4DATE:
10/17/2022
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Mohammed Shirazi, AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility fails to provide residents with a nutritious diet.
Facility ran out of diapers for residents in care.
Staff are not allowing resident to use personal chair.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Galarza & Kimberly Ramirez and Eastern Los Angeles Regional Center Community Services Specialist Luciana Cruz conducted an initial 10-Day complaint visit to investigate the above allegations. The purpose of the visit was discussed with staff Francis Chavez. Interim Administrator Mohammed Shirazi arrived shortly after and was explained the purpose of the visit.

The investigation consisted of: A physical plant tour of the home, food supply, garage storage areas, food supply, incontinence supply inventory, file reviw, and staff interviews were conducted. Staff (S1- S3) were interviewed. Due to developmental disability all clients are non-verbal and were not interviewed. Client (C1's) Face Sheet, Physician Report, Individual Program Plan (IPP) and client (C2-C4's) Physician's Reports documents were obtained.

See LIC 9099C for report continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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 5
Control Number 28-AS-20221010151359
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: KAISER SPECIALIZED RESIDENTIAL FAIRVIEW
FACILITY NUMBER: 198600948
VISIT DATE: 10/17/2022
NARRATIVE
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Allegation: Facility fails to provide residents with a nutritious diet. It is alleged that the facility does not have sufficient fresh food and residents are primarily served highly processed foods i.e. bologna, hot dogs, and frozen food meals that are not nutritious. Based on observation, the findings indicate the facility food supply is primarily based of frozen prepackaged food items and/or meals like waffles, chicken breast patties, bologna, sausage hot dogs, frozen cheeseburgers, frozen vegetables, cheese, eggs, canned foods, and fruit juice punch. The facility had low supply of fresh fruit and vegetables, and fresh protein food items. Due to insufficient fresh food, today's menu items have been substituted with other food frozen food items. Resident files were reviewed. Per Physician Report, two (2) out of four (4) residents have hypertension and have physician orders for pureed or mechanical soft diets. Additionally, the facility's emergency water supply is not being replaced and there is very little water supply for residents. A total of (3) staff were interviewed all confirmed that there is currently no emergency water supplies in storage. Facility protocol is to have a minimum of two (2) gallons of water per resident. The facility has an approved General Healthful Die (GHD) food menu created by a Registered Dietician that states: "This GHD is also consistent with the heart healthy, low fat, low sodium and consistent carbohydrate diet)." Therefore, there is evidence to prove that the facility has insufficient fresh perishable foods for a minimum of two days.

Allegation: "Facility ran out of diapers for residents in care." It is alleged that the facility ran out of incontinence resident diapers many months ago and staff has had to buy supplies with their own money, and/or bring supplies from other facilities in order to meet the resident's incontinence needs. Based on interviews conducted residents (R3 & R4) are incontinent and require 5-6 diapers per day. Resident (R1) does not use incontinence diapers, and resident (R2) uses incontinence pull-ups. The facility is supposed to renew the incontinence supplies contract yearly so that supplies are delivered monthly. However, the renewal referral was not submitted in late 2021 by previous Administrator. As a result, the facility has been using surplus supplies from other facilities. During today's visit, only incontinent liners were observed to be sufficient. The facility only has one case that contains 4 packs of 10 diapers; which is not sufficient to meet the incontinence needs of the residents. Per Administrator, an incontinence supply referral to J & B Medical was submitted on September 22, 2022.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20221010151359
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: KAISER SPECIALIZED RESIDENTIAL FAIRVIEW
FACILITY NUMBER: 198600948
VISIT DATE: 10/17/2022
NARRATIVE
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Allegation: "Staff are not allowing resident to use personal chair." It is alleged that resident (R1) has an electrical recliner massage chair that was moved to the garage, is not accessible to the resident, and has not been used by the resident in months. It is also alleged, the chair was purchased with COVID-19 stimulus check monies and placed in the living room, but was removed from the home in order to make more space in the living room. According to staff interviews, non-verbal resident (R1) was uncomfortable in the electrical recliner chair and previous Administrator was informed. Mr. Calderon gave staff the directive to remove R1's chair. The resident was provided R4's old recliner chair as a replacement. However, R1's responsible party and Eastern Los Angeles Regional Center Service Coordinator were not notified about the non-use of the electrical chair. The resident's chair was observed in the garage. Pictures were taken of the stored chair.

Based on interviews conducted, record review, and observations, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D.

Exit interview was conducted with Interim Administrator Mohammed Shirazi. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20221010151359
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: KAISER SPECIALIZED RESIDENTIAL FAIRVIEW
FACILITY NUMBER: 198600948
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited
CCR
85076(d)(1)
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Food Service. The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
This requirement was not met evidence by:
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Administrator shall submit:

1.A written plan stating how this deficiency was corrected.
2. Proof that an RD evaluated the food menu
3. Proof that fresh foods were purchased
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Based on observation, the findings indicate that the facility has insufficient fresh perishable food and is primarily serving residents frozen prepackaged foods that are not nutritious. This poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/28/2022
Section Cited
CCR
80077.4(b)(1)
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Care for Clients with Incontinence. If a licensee accepts or retains a client who has bowel and/or bladder incontinence, the licensee is responsible for all of the following:
(1) Ensuring that incontinent care products appropriate to the needs of the client are used whenever they are needed. This requriement was not met evidenced by:
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Administrator shall provide that the incontinence supplies were ordered for the residents, and shall ensure there is a surplus of incontinence supplies in case of an emergency.

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Based on observation, the findings indicate that the facility has very low supply of incontinence diapers for residents (R3 & R4), and supplies have not been delivered in many months. The facility is bringing limited supplies from other facilities; which poses a potential health, safety or personal rights risk to persons in care.
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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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20221010151359
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: KAISER SPECIALIZED RESIDENTIAL FAIRVIEW
FACILITY NUMBER: 198600948
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited
CCR
80072(a)(2)
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Personal Rights. (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: ( 2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met evidenced by:
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Administrator shall provide a written statement that states how this deficiency was corrected.
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Based on observation, resident (R1's) personal electrical recliner chair was removed and placed in the garage because the resident was not comfortable. However, R1's responsible party and Regional Center were not notified of the change. This poses a potential health, safety or personal rights risk to persons in care.
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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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5