198601320-11-27-2023-28-AS-LHIS-CYVNUK-20231226094626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601320
Report Date: 11/27/2023
Date Signed: 11/27/2023 04:24:00 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
11/20/2023 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20231120120058

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:	11/27/2023
		UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Administrator Mona DeLa Rosa		TIME COMPLETED:	04:38 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not meet residents' diapering needs
Staff did not provide activities for residents

INVESTIGATION FINDINGS:

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

On 11/27/2023 at 8:42 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an initial complaint visit to investigate the above allegations. Upon arrival LPA met with Staff #1 (S1) and explained the reason for the visit. S1 contacted Administrator Mona DeLa Rosa via phone. The Administrator Mona De La Rosa arrived at 9:01 a.m. and assisted with the rest of the visit.

During today’s visit: A tour of the interior, and exterior facility was completed; with a focus on the bedrooms, and bathrooms. LPA obtained a copy of staff roster, resident roster, photo of incontinent supplies, photo of activities, and Leisure Activities Log. LPA conducted file review for clients C1 through C6 and obtained the following documents: Individual Program Plan (IPP), Physician’s Report, and Pre-Placement appraisal. LPA interviewed the administrator and a total of two (2) staff who shall be referred to as S1 and S2. LPA also interviewed a total of 6 clients who shall be referred to as C1 through C6. LPA was unable to use the interviews for C3 and C4 due to their diagnosis. C5 and C6 refused interviews.
Report Continued on 9099c

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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-20231120120058

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: 11/27/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation reveals the following: Regarding “Staff did not meet residents' diapering needs”. It is alleged that the clients sit in three (3) diapers, so that staff do not have to change them. The Administrator denied the allegation stating staff are required to check the clients every 2 hours. The administrator further denied witnessing staff leaving clients in three diapers during the day. 2 out of 2 staff denied the allegation stating they change the clients every two (2) hours, and they wear one (1) diaper at a time. 2 out of 6 clients stated staff assist them with diaper changes with no problems. 4 out 6 client’s interviews could not be used. During the tour LPA Baptiste observed sufficient incontinent supplies and did not observe incontinent odors in the facility.

The investigation reveals the following: Regarding “Staff did not provide activities for residents”. It is alleged that the clients sit in their wheelchair all day long. The Administrator denied the allegations, stating 5 of the clients attend a day program Monday through Friday, and 1 client attend school Monday through Friday from 7:30 to 4pm. 2 out of 2 staff denied the allegation stating the clients attend day program Monday through Friday. Staff further stated during the weekend the clients attend community outings, stores, restaurants, Car Museum and engage in activities such as bingo, coloring, and use beads for necklace and bracelet making. During the tour LPA observed Beads, Uno cards, Monopoly, Scribble, and Coloring supplies. 2 out of 6 clients stated they participate in different activities with the assistance of the staff. 4 of 6 client’s interview could not be used. LPA reviewed each client leisure activities log and observed the clients do an activity between one (1) to thirteen (13) times a month, depending on the client.

Based on LPA's interviews, investigation revealed: 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.

Exit interview conducted with Mona De La Rosa and a copy of this record provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2