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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601448
Report Date: 09/30/2024
Date Signed: 09/30/2024 04:14:29 PM

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
07/06/2022 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220706165023
FACILITY NAME:A AND M III HOME CAREFACILITY NUMBER:
198601448
ADMINISTRATOR:ROBERTO RONASFACILITY TYPE:
735
ADDRESS:537 CONVERSE AVETELEPHONE:
(909) 618-7065
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 4DATE:
09/30/2024
UNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Ana Alarcio, Administrator and ana De La Rosa, Licensee. TIME COMPLETED:
04:34 PM
ALLEGATION(S):
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Questionable Death.
Facility staff did not provide timely medical attention to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made subsequent visit to deliver findings for complaint received on 07/06/2022. LPA met with Ana Alarcio, Administrator and Licensee arrived a short time later and LPA discussed the purpose of the visit.

On July 8, 2022 Licensing Program Analyst (LPA) Alberto Lopez conducted a Health and Safety Check visit in response to the above-mentioned allegations. LPA met with Administrator Ana Alarcio and the reason for the visit was discussed. Licensee Mona De La Rosa arrived later and assisted with visit.
Investigation consisted of the following: LPA requested copies of Client & Staff Rosters and conducted a tour of facility at 8:21 AM along with Administrator Ana Alarcio which also included the common areas. LPA also reviewed and received copies from Client #1's (C1) file. LPA observed the clients to identify any signs of neglect, abuse, or other immediate health and safety threats.
(CONTINUED ON 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
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-20220706165023
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 AND M III HOME CARE
FACILITY NUMBER: 198601448
VISIT DATE: 09/30/2024
NARRATIVE
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LPA did not observe any immediate health and/or safety concerns during today's visit. LPA observed a sufficient supply of perishable and non-perishable foods for the clients in care.
LPA requested copy of file of C1 for 11/2021 - 04/2022 and Administrator will send copy to LPA.
LPA Interviewed Five (5) staff (S#1-S#5) and one witness (W1) and attempted to interview four clients(4) (C#1-C#4).

Allegation: Questionable Death. It is alleged that facility failed in their responsibility to provide care and supervision and it led to the death of C1
The investigation revealed:

LPA interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPA was not able to interview any clients. LPA interviewed one witness from Regional Center Witness #1

According to Department interviews, and records reviewed, client was found by DSP S4 at approximately 6:30 – 6:45AM on 4/23/22. When S4 found C1 unresponsive. S4 noted that client had no pulse on C1 wrist. S4 also noted that C1 chest was not rising, and saliva was coming out of C1 mouth with bubbles. S4 called for S5 to come to room, telling S5 that S4 thought C1 was dead. S5 noticed client was not moving, was pale, yellowish and had saliva coming out of C1 mouth. Neither staff touched client. 911 was called and call did not initially go through. 911 was called again and 911 operator asked S4 if client was responsive. S4 said no. 911 operator asked if S4 could perform CPR. I don’t think so because S4 thought client was “gone”. S4 stated S4 didn’t want to make matters worse. According to S4 911 operator told S4, I understand, wait for paramedics. When paramedics arrived at the facility, they declared client dead.

According to records reviewed, when paramedics arrived, they observed that the client was deceased. Paramedics performed chest compressions. Documents show that C1 had been deceased at least 2 hours prior to arrival of paramedics

The 1:1 staff (S2) who was assigned to supervise resident from 4/22/2022 at 10pm to 4/23/2022 at 6 am failed to monitor resident closely and to seek for help when resident had tonic-clonic seizure, leading to C1 death of Cardiopulmonary arrest. Resident was already deceased before the morning shift arrived on 4/23/2022 at 6:30 am., when they found resident unresponsive with no pulse and rigor mortis was present.

The death of C1 was the result of a tonic-clonic seizure that causes violent muscle contraction and gurgling sounds that should’ve alerted S2, who was the clients 1:1 that night, that C1 was in distress and summoned medical attention immediately for C1. S2 stated S2 did not hear or observed anything during S2 shift. Facility did not provide satisfactory care and supervision to meet C1 needs. There is sufficient evidence to substantiate this allegation.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20220706165023
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 AND M III HOME CARE
FACILITY NUMBER: 198601448
VISIT DATE: 09/30/2024
NARRATIVE
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Allegation: Facility staff did not provide timely medical attention to resident in care.

The investigation revealed.

According to Department interviews, and records reviewed, C1 was found by DSP S4 at approximately 6:30 – 6:45AM on 4/23/22. When S4 found C1 unresponsive, S4 noted that C1 had no pulse on C1 wrist. S4 also noted that C1 chest was not rising, and saliva was coming out of clients mouth with bubbles. S4 called for S5 to come to room, telling S5 that S4 thought C1 was dead. S4 noticed C1 was not moving, was pale, yellowish and had saliva coming out of C1 mouth. Neither staff touched C1. 911 was called and call dd not initially go through. 911 was called again and 911 operator asked S4 if client was responsive. S4 said no. 911 operator asked if S4 could perform CPR. I don’t think so because S4 thought C1 was “gone”. S4 stated S4 didn’t want to make matters worse. According to S4 911 operator told S4, I understand, wait for paramedics. When paramedics arrived at the facility, they declared C1 dead at 6:54AM. Review of records indicate that C1 had been deceased for at least 2 hours prior to being discovered by S4. According to records reviewed, the death of C1 was the result of a tonic-clonic seizure that causes violent muscle contraction and gurgling sounds that should’ve alerted S2, who was the C1's 1:1 that night, that C1 was in distress and summoned medical attention for C1. S2 stated S2 did not hear or observed anything during S2 shift. Facility did not provide timely medical attention to client when client was in distress while having tonic-clonic seizure.

The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED.

The facility has been informed that Immediate civil penalty is being issued during today’s visit in the amount of $500.00, based on health and safety code 1569.49.

“The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). “

An exit interview was conducted with Administrator and Licensee. A copy of this report along with the appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20220706165023
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 AND M III HOME CARE
FACILITY NUMBER: 198601448
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2024
Section Cited
CCR
80078(a)
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80078(a) Responsibility for providing care and supervision.
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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Licensee will read section 80078(a) and write a letter to CCL explaining licensee understands and how this will be prevented in the future by POC date.

**Immediate Civil Penalties will be assessed in the amount of $500.00.**
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Licensee failed to provide supervision and care to C1 resulting in C1 having a tonic-clonic seizure that led to C1 death.
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Type A
10/01/2024
Section Cited
CCR
80075(a)
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80075(a) 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,

This requirement is not met by:
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Licensee will provide training to staff to make sure they respond when they notice a change of condition or if client is in distress. licensee will provide POC by due date.
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Based on interviews and records review, the licensee did not comply with the section cited above as facility staff did not seek medical care in a timely manner for C1 when C1 was in distress and having a seizure, which poses an immediate health, safety or personal rights risk to persons in care.
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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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4