<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601637
Report Date: 02/07/2025
Date Signed: 02/07/2025 02:35:16 PM

Unsubstantiated


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
01/31/2025 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250131162807
FACILITY NAME:ST. DANIEL'S HOME FOR THE ELDERLY II, INC.FACILITY NUMBER:
198601637
ADMINISTRATOR:DEBORAH DAVISFACILITY TYPE:
740
ADDRESS:2315 NAVARRO DRIVETELEPHONE:
(909) 624-1286
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 4DATE:
02/07/2025
UNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Caregiver Justin TrinidadTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not follow doctor's orders for resident's medication.
Staff did not provide medical assistance to resident.
Staff withheld resident's hearing aids.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 2/6/2025 regarding the above allegations. LPA was greeted by Caregiver Justin Trinidad and explained the purpose of the visit. Administrator Deborah Davis arrived shortly after to assist with visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 3 interviews (S1 – S3), Interview of Resident#1-4 (R1 – R4), Attempted interview of Resident#5 (R5), Copies of R5’s: Admission Agreement, Physician’s Report (LIC 602A), Centrally Stored Medication and Destruction Record (LIC 622), Hospice Care Plan, Medication Administration Record (MAR) for the month of December 2024 & January 2025, Identification and Emergency information form (LIC 601), Resident Appraisal (LIC 603A), Preplacement Appraisal Information (LIC 603) Client/Resident Personal Property and Valuables (LIC 621) and physical plant tour.

See 9099-C for continued report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
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 3
Control Number 28-AS-20250131162807
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: ST. DANIEL'S HOME FOR THE ELDERLY II, INC.
FACILITY NUMBER: 198601637
VISIT DATE: 02/07/2025
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 revealed the following: Regarding allegation(s): Staff did not follow doctor's orders for resident's medication. It is alleged staff did not administer R5 morphine according to R5’s physician orders. R5 was admitted into the facility on 12/29/2024. During record review, LPA Ramirez observed a physician’s order for PRN (as needed) medication of morphine sulfate powder 100/5ML-give 0.25 milliliter for pain every 4 hours, with a start date of 12/30/2024. On 01/05/2025, R5’s physician ordered R5’s PRN of morphine sulfate powder 100/5ML- 0.25 milliliter for pain every 4 hours to change to every 2 hours-administer 0.5ML (10mg) and is now to be administered as a scheduled medication. Review of R5’s MAR for 12/30/2024 through 1/4/2025, revealed staff administered morphine sulfate as a PRN, per R5’s physician orders. Review of R5’s MAR dated 1/5/2025 through 1/6/2025, revealed staff administered morphine sulfate as a scheduled medication, per R5’s physician order. Three (3) out of the three (3) staff interviewed denied this allegation. Four (4) out of the four (4) residents interview denied this allegation. R5 is not available for an interview. LPA Ramirez contacted R5’s responsible party via phone but, R5’s responsible party was unavailable for an interview. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Staff did not provide medical assistance to resident. It is alleged staff did not provide R5 with first aid to a wound on R5’s arm. R5 began receiving hospice care on 12/29/2024. Three (3) out of the three (3) staff interviewed denied this allegation. Staff interviews revealed, on 1/3/2025, staff#1 (S1) saw 2 drops of dried blood on the left edge sleeve of R5’s white tee shirt. S1 checked R5’s left arm and saw a small scratch, no larger than a quarter on R5’s lower arm. S1 revealed the scratch was not bleeding at the time and did appear to need first aid. S1 revealed later that day R5’s responsible party visited R5 and pointed out the dried blood drops on R5’s shirt. S1 advised R5’s responsible party of earlier observation. S1 stated “Hospice was on their way to assess R5 and I asked them to look at R5’s arm, the nurse said it appeared like a small scratch.” LPA Ramirez reviewed hospice care notes dated 1/3/2025 and 1/5/2025 and did not observe hospice care staff document any new injuries to R5 or R5 requiring wound care during visits. Four (4) out of the four (4) residents interview denied this allegation. R5 is not available for an interview. LPA Ramirez contacted R5’s responsible party via phone but, R5’s responsible party was unavailable for an interview. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

SEE 9099-C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250131162807
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: ST. DANIEL'S HOME FOR THE ELDERLY II, INC.
FACILITY NUMBER: 198601637
VISIT DATE: 02/07/2025
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
Staff withheld resident's hearing aids. It is alleged staff withheld R5’s hearing aids. Three (3) out of the three (3) staff interviewed denied this allegation. Four (4) out of the four (4) residents interview denied this allegation. R5 is not available for an interview. LPA Ramirez contacted R5’s responsible party via phone but, R5’s responsible party was unavailable for an interview. Staff interviews revealed, R5 was able to remove their own hearing aids and would remove them before bed so staff could charge them. Staff revealed R5 would sometimes request to have staff remove R5’s hearing aids. Although staff interviews revealed R5 had hearing aids, LPA Ramirez observed Client/Resident Personal Property and Valuables (LIC 621) form; section B- Personal property/valuables removed- indicating hearing aids, glasses and a wedding band were removed by R5’s responsible party on 12/29/2024 and was signed by R5’s responsible party. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No violations were cited during this visit. Exit interview was conducted. A copy of this report was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3