198601356-3-17-2026-28-AS-WSHO-DUNVH8-20260602162642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601356
Report Date: 03/17/2026
Date Signed: 03/17/2026 02:02:41 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
08/21/2025 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250821173356

FACILITY NAME:	GEMLY'S HOME CARE III		FACILITY NUMBER:	198601356
ADMINISTRATOR:	GEMMA RODRIGUEZ		FACILITY TYPE:	735
ADDRESS:	19002 HOLLYVALE DRIVE		TELEPHONE:	(626) 335-2151
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY:	6	CENSUS: 6	DATE:	03/17/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Staff S1		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Questionable Death
Staff retaliate against residents for reporting concerns
Staff left residents in soiled diapers for extended periods of time
Staff did not safeguard resident's personal items
Staff did not accord resident privacy
Staff did not treat resident with respect
Unlawful eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman conducted a subsequent complaint visit pertaining to the above-mentioned allegations. LPA met with Staff S1 and explained the reason for the visit.
The initial complaint visit was a Health and Safety Check conducted on 08/25/2026.
At today's visit 3/17/2026 the following was done:
Resident and Staff Roster were submitted.
Interviews were conducted with the Administrator Gemma Rodriguez telephonically, Staff S1, and Staff S2, Staff S3 and Staff S4 telephonically.
Client's C2- Client's C4 and Client C7 was interviewed.
An Investigation was conducted by Investigator Garcia of the Investigations Branch (IB) and completed 02/19/2026 for the allegation of Questionable Death.
Investigation consisted of interviews with facility staff, residents, review of medical documentation and Special Incident Reports (SIR's) from San Gabriel Pomona Regional Center.
Death Certificates for Client's C5 and Client C6 were reviewed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

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 4

Control Number 28-AS-20250821173356

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: GEMLY'S HOME CARE III	FACILITY NUMBER: 198601356
	VISIT DATE: 03/17/2026

NARRATIVE

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In regards to the allegation Questionable Death, during the investigation Death certificates for Client's C5 and C6 were obtained and reviewed, indicating both deaths resulted from natural causes and/or pre-existing medical conditions. Was also confirmed through inquiries with the Los Angeles County Medical Examiner’s Office, Los Angeles County Morgue, and the certifying physicians that no autopsy reports were available for either resident. Staff reported that the residents were regularly monitored and exhibited no signs of illness prior to their passing.
It should also be noted that an investigation was conducted by the Investigations Branch (IB) Investigator Brian Slatic from the Department of Social Services and completed 3/25/2021
Complaint Control # 28-AS-20201223092631.
The allegation Staff neglect resulted in clients sustaining a death while in care, and the findings were Unsubstantiated. This was regarding Client's C5 and Client's C6.

In regards to the allegation Staff retaliate against residents for reporting concerns, based on interviews conducted and information gathered Client's C2- C4 and C7 it was revealed that staff have not communicated not to report to licensing to the clients. All stated there was never a client retaliated against.
All stated that staff treats them well.
Administrator and Staff S1- Staff S4 all stated that staff have never told clients to not report to licensing. All stated there has never been retaliation.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove
alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

In regards to the allegation Staff left residents in soiled diapers for extended periods of time, based on interviews conducted and information gathered all client's interviewed stated that clients are not left in

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20250821173356

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: GEMLY'S HOME CARE III	FACILITY NUMBER: 198601356
	VISIT DATE: 03/17/2026

NARRATIVE

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soiled diapers.
Client C2 who was a roommate of C1 stated that Client C1 would often soil the diaper and not inform staff.
Said staff would often encourage Client C1 to reach out for their help.
Staff S1 stated that C1 would be in the dining room and on the computer and would smell of going to the restroom in the diaper. They'd encourage C1 who would keep saying later.
Administrator and Staff stated that there are no soiled diapers and they are checked frequently.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove
alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

In regards to the allegation Staff did not safeguard resident's personal items, based on interviews conducted and information gathered all clients stated that all items that they were admitted to the facility with are still there.
Client C2 stated that items of C1 were in the garage and on the computer table. Said C1 did not communicate to staff at all about the belongings, but there was just a little belongings in the room.
All clients said staff are kind and do a great job.
Staff stated that C1 had only a little belongings and that no items were ever taken.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove
alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

In regards to the allegation Staff did not accord resident privacy, based on interviews conducted and information gathered Client C2 stated that C1 had alot of food and drinks in the room. Said if C1 was out in the community C2 would give staff the ok to come in and clean.
Client's C2, C3, C4, and C7 all stated that staff always give them privacy and don't ever just walk in their room.
Staff stated that they are always allowing the clients privacy and they are treated well.
All said that staff allow the clients to have their personal rights.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove
alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

In regards to the allegation Staff did not treat resident with respect, based on interviews conducted and

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20250821173356

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: GEMLY'S HOME CARE III	FACILITY NUMBER: 198601356
	VISIT DATE: 03/17/2026

NARRATIVE

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information gathered all clients stated that staff will assist with doctor appointments and they prefer that because staff will remember the important information and help them also with medication adjustments.
Client C2 stated that C1 understood why staff would go with them. Said that C1 would withhold pertinent medical information from staff.
Said C1 would willingly not mention to anybody even if it was an important appointment.
Staff all stated that they assist on doctor appointments so they can provide excellent care in whatever needs there are at the facility.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove
alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

In regards to the allegation Unlawful eviction Administrator stated that C1 was never served with an eviction.
Said C1 had been admitted into the hospital for various illnesses.
Stated that the facility could not meet C1's need so C1 was relocated by the Regional Center.
All staff stated that there has never been anyone served with an eviction.
All clients stated they never heard of anyone being evicted.
All stated they are treated very well.

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

It should be noted that Client C1 no longer resides at the facility as of 2021.

Exit interview and copies provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC9099 (FAS) - (06/04)

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