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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601320
Report Date: 12/29/2022
Date Signed: 12/29/2022 11:38:29 AM

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
04/01/2020 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200401153111
FACILITY NAME:A & M II HOME CAREFACILITY NUMBER:
198601320
ADMINISTRATOR:ARIEL P. DELA ROSAFACILITY TYPE:
735
ADDRESS:1476 MURAL DRIVETELEPHONE:
(909) 618-7064
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 5DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mona De La Rosa - LicenseeTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Failure to obtain prompt medical care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent investigation visit for the allegation – failure to obtain prompt medical care. LPA met with Mona De La Rosa (Licensee) and explained the purpose of the visit.

The investigation consisted of the following:

On 04/03/2020, LPA Ren’ee Arterberry conducted an initial investigation visit and obtained the requested documents: Individual Program Plan (IPP), Identification Page/Pace Sheet, Health Screening and all medical documents pertaining to a client who shall be referred to as Client 1 (C1). On 04/09/2020, this allegation was assigned to an Investigation Branch (IB) Investigator to complete the investigation.

(CONTINUED TO LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
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-20200401153111
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 & M II HOME CARE
FACILITY NUMBER: 198601320
VISIT DATE: 12/29/2022
NARRATIVE
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The investigation revealed the following:

Allegation - failure to obtain prompt medical care. During the investigation, interviews were conducted and medical records were obtained. IB Investigator interviewed 12 individuals which included San Gabriel/Pomona Regional Center Quality Assurance Specialist, C1’s Service Coordinator, Home Facility Licensee, Home Facility Administrator, Home Facility Staff, Home Facility Clients, ADP’s Administrator, ADP’s Assistant Administrator, and ADP’s Staff Members. Interviews with ADP staff revealed that on 12/02/2019, C1 arrived at the Adult Day Program (ADP) with an injured finger and the ADP staff documented the injury in C1’s communication logbook. C1 carries the communication logbook daily to the ADP and back to the home facility. On 12/05/2019, the ADP contacted the home facility’s administrator regarding the status of C1's injury since C1 continued to show up at the ADP with the injury and was in pain. On the afternoon of 12/05/2019, the home facility staff took C1 to the hospital where C1 was diagnosed with a fractured finger. Interviews with home facility staff revealed that C1 came home from the ADP with a swollen finger on 12/02/2019 and believed C1 had been bitten by an insect. They applied ointment on the finger until they took C1 to the hospital on 12/05/2019.

Based on interviews and documents, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1, are being cited on the attached LIC 9099D.

An exit interview was conducted. A copy of this report and appeal rights were provided to Mona De La Rosa (Licensee).
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20200401153111
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 & M II HOME CARE
FACILITY NUMBER: 198601320
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited
CCR
80075(a)
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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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Facility is to ensure that Title 22 Section 80075 regulations are met at all times. Additionally, an in-service training is to be conducted regarding Title 22 Section 80075 and a training log with staff signature submitted to CCLD by 01/06/2023.
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This requirement is not met by:

Based on interviews and records review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Facility did not seek medical care in a timely manner.
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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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
04/01/2020 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200401153111

FACILITY NAME:A & M II HOME CAREFACILITY NUMBER:
198601320
ADMINISTRATOR:ARIEL P. DELA ROSAFACILITY TYPE:
735
ADDRESS:1476 MURAL DRIVETELEPHONE:
(909) 618-7064
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 5DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mona De La Rosa - LicenseeTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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2
3
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9
Resident sustained a fracture while in care
INVESTIGATION FINDINGS:
1
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3
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5
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7
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11
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13
Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent investigation visit for the allegation – failure to obtain prompt medical care. LPA met with Mona De La Rosa (Licensee) and explained the purpose of the visit.

The investigation consisted of the following:

On 04/03/2020, LPA Ren’ee Arterberry conducted an initial investigation visit and obtained the requested documents: Individual Program Plan (IPP), Identification Page/Pace Sheet, Health Screening and all medical documents pertaining to a client who shall be referred to as Client 1 (C1). On 04/09/2020, this allegation was assigned to an Investigation Branch (IB) Investigator to complete the investigation.

(CONTINUED TO LIC 9099C)

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20200401153111
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 & M II HOME CARE
FACILITY NUMBER: 198601320
VISIT DATE: 12/29/2022
NARRATIVE
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The investigation revealed the following:

Allegation - resident sustained a fracture while in care. During the investigation, interviews were conducted and medical records were obtained. IB Investigator interviewed 12 individuals which included San Gabriel/Pomona Regional Center Quality Assurance Specialist, C1’s Service Coordinator, Home Facility Licensee, Home Facility Administrator, Home Facility Staff, Home Facility Clients, ADP’s Administrator, ADP’s Assistant Administrator, and ADP’s Staff Members. Interviews ADP staff revealed that on 12/02/2019, C1 arrived at the Adult Day Program (ADP) with an injured finger and the ADP staff documented the injury in C1’s communication logbook. C1 carries the communication logbook daily to the ADP and back to the home facility. On 12/05/2019, the ADP contacted the home facility’s administrator regarding the status of C1's injury since C1 continued to show up at the ADP with the injury and was in pain. On the afternoon of 12/05/2019, the home facility staff took C1 to the hospital where C1 was diagnosed with a fractured finger. Home facility staff stated that C1 came home from the ADP with a swollen finger on 12/02/2019 and believed C1 had been bitten by an insect. There is no evidence to show that the fracture occurred at the home facility or the ADP. Investigation Branch (IB) unsubstantiated the allegation that C1 sustained the finger fracture while in the care of the home facility.

Based on interviews and documents, the preponderance of evidence standard has not been met, therefore, the above allegation is found to be UNSUBSTANTIATED.

An exit interview was conducted. A copy of this report was provided to Mona De La Rosa (Licensee).
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5