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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601186
Report Date: 02/03/2023
Date Signed: 02/03/2023 10:13:16 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
09/16/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220916092900
FACILITY NAME:GRACEFULL LIVINGFACILITY NUMBER:
198601186
ADMINISTRATOR:TAMARA SMALLEYFACILITY TYPE:
735
ADDRESS:1992 WILDROSE AVETELEPHONE:
(909) 461-3360
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:6CENSUS: 5DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Denene Owens/S-3TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff did not provide a comfortable environment for resident in care.
Staff are not meeting residents needs.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Elizabeth Irra and Tena Herrera conducted a subsequent investigation visit to investigate the above allegations. LPAs were allowed entry by Denene Owens. LPAs explained the purpose of today's visit. The initial 10-day complaint visit was conducted on 09/21/22.
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During this investigation, LPA obtained copies of the staff and client rosters, copy of the
visiting policy and sign-in sheet for visitors. LPA attempted to interview Client #1 through Client #5 (C-1 through C-5) and was unsuccessful as they are non-verbal. LPA interviewed Staff #1 (S-1) through Staff #3 (S-3). LPA interview San Gabriel Pomona Regional Center. LPA also reviewed C-1s file and collected relevant documentation.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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-20220916092900
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: GRACEFULL LIVING
FACILITY NUMBER: 198601186
VISIT DATE: 02/03/2023
NARRATIVE
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Allegation Staff did not provide a comfortable environment for resident in care. LPA attempted to interview Client #1 through Client #5 (C-1 through C-5) and was unsuccessful as they are non-verbal. Staff interviews revealed that staff provide comfortable environment for clients in care. Staff indicated the family room is the primary room used for visitation. Staff interviewed indicated that staff do not put chairs out in the sun in the heat for visitation. Additionally, interviewed staff indicated the facility has a visiting policy and sign-in sheet for visitors and visitors undergo COVID-19 screening. Staff interviews revealed that staff have not received any concerns/complaints in regards to staff not providing a comfortable environment for clients. Interview with San Gabriel Pomona Regional Center revealed that a comfortable environment is being provided to client and that they have not received any concerns/complaints. Interviews conducted and collected documentation does not corroborate this allegation.

Allegation: Staff are not meeting residents needs. LPA attempted to interview Client #1 through Client #5 (C-1 through C-5) and was unsuccessful as they are non-verbal. Staff interviews revealed that staff are meeting client needs. Staff interviews revealed that staff have not received any concerns/complaints in regards to staff not meeting client needs. Interviewed staff indicated that all clients receive the necessary medical care. Interview with San Gabriel Pomona Regional Center revealed that staff are meeting client needs and that they have not received any concerns/complaints. Interviews conducted and collected documentation does not corroborate this allegation.

Although the allegations may have happened or is 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, copy of report and Appeal Rights were provided to Denene Owens

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
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