198601320-9-29-2023-28-AS-RORN-CX6L9J-20231101083338

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601320
Report Date: 09/29/2023
Date Signed: 09/29/2023 03:11:14 PM

Unsubstantiated

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
09/25/2023 and conducted by Evaluator Valeria Maldonado

COMPLAINT CONTROL NUMBER: 28-AS-20230925095233

FACILITY NAME:	A & M II HOME CARE		FACILITY NUMBER:	198601320
ADMINISTRATOR:	ARIEL P. DELA ROSA		FACILITY TYPE:	735
ADDRESS:	1476 MURAL DRIVE		TELEPHONE:	(909) 618-7064
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 6	DATE:	09/29/2023
		UNANNOUNCED	TIME BEGAN:	12:09 PM
MET WITH:	Mona Dela Rosa- Licensee		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not meet incontinence needs of resident.
Staff do not provide activities for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unnanounced complaint visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Direct Support Professional (DSP), Jane Garcia, and explained the purpose for the visit. Licensee Mona Dela Rosa arrived shortly after and assisted with the visit.

During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, conducted a tour of the physical plant with Licensee, Mona, and obtained the following records for Clients# 1-6 (C1-C6): Planned Activities Calendar, Charting Notes for continence care, if any, Facesheet, Physician's Report, Pre-Placement Appraisal, and Individual Program Plan (IPP). (4) Clients were at the home during today's visit, and (2) were out of the community. LPA attempted to conduct interviews with Clients# 1-4 (C1-C4) at the home, and telephonic interviews were attempted with C5 and C6, at their respective programs. However, LPA was unable to reach them. Interviews with Staff# 1-4 (S1-S4) were also conducted.
(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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-20230925095233

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: A & M II HOME CARE	FACILITY NUMBER: 198601320
	VISIT DATE: 09/29/2023

NARRATIVE

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Regarding allegation: Staff do not meet incontinence needs of resident.
It is alleged that staff put (3) adult briefs on a client and left the client to sit in urine soaked briefs, rather than assisting them to use the restroom. (4) of (4) staff denied the allegation. Staff stated that the all clients wear briefs in case of an accident, but most can toilet independently. Staff state facility policy is to check all clients every two hours and as needed for brief changes. They stated clients are changed whether soiled or not. Per client's IPP's and Physician's Reports, (4) of (6) clients can toilet independently. Per client's IPP's, (2) of (6) clients require incontinence care, and the facility continues to meet client's needs and are appropriately placed. (4) of (6) clients interviewed could not corroborate the allegation. During the facility tour, LPA observed a sufficient amount of incontinence supplies for clients in care, labeled and organized by client name/sizes. LPA inspected client rooms and bathrooms and observed them to be clean, sanitary, and free of odors. LPA also observed clients for any signs of neglect and noted that clients were all wearing clean clothing, were free from odors, and were observed to be comfortable while sitting, doing different activities. This allegation is Unsubstantiated.

Regarding allegation: Staff do not provide activities for resident.
It is alleged that a client is left in their wheelchair all day long and is not provided with any activities. (4) of (4) staff interviewed denied the allegation. It was stated that all clients attend day program during the week and have facility outings at least once a week to different places they choose. They also stated clients engage in activities of their choice when they return from their program. (2) of (6) clients interviewed stated they like the activities at the facility, which include coloring, watching tv, going to the mall, going out to eat, and going shopping. C2 stated that every Tuesday, clients participate in deciding where their upcoming outing will be. (4) of (6) clients could not corroborate the allegation. Per the Client's Activities Calendar, it is noted that clients have had outings at least twice a month, every month since January 2023. This allegation is Unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is Unsubstantiated.

Per California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies are being cited.

An exit interview was conducted with Licensee, Mona Dela Rosa and a copy of this report was provided

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

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