198601772-4-27-2022-28-AS-MVAO-CEBQWL-20220511123209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601772
Report Date: 04/27/2022
Date Signed: 04/27/2022 03:07:21 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
07/07/2021 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210707164610

FACILITY NAME:	A AND M IV HOME CARE		FACILITY NUMBER:	198601772
ADMINISTRATOR:	ARIEL P. DELA ROSA		FACILITY TYPE:	735
ADDRESS:	226 E. ANNAPOLIS DRIVE		TELEPHONE:	(909) 618-7064
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	4	CENSUS: 3	DATE:	04/27/2022
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Mona De La Rosa Licensee/ Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff neglect resulting in resident being malnourished.
Resident suffered from dehydration while in care.
Resident developed a UTI infection while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA's) Valeria Maldonado and Ashley Calderon conducted a subsequent complaint investigation visit for the above allegations. The initial visit was conducted by LPA Linda Almaraz on 07/08/2021. LPA's met with Moana De La Rosa Licensee / Administrator and discussed the purpose of today’s visit.

On 07/08/2021, LPA Almaraz conducted a 24 hour health and safety check. LPA Almaraz conducted a tour of the living room, dining areas, kitchen, common areas and random resident rooms. The kitchen had sufficient perishable and non-perishable food. Water temperature was tested. Resident rooms and common areas were properly furnished. LPA Almaraz did not observe any signs of neglect, or abuse. Additionally, LPA Almaraz requested copies of staff and resident roster along with Resident #1 and #2 files.
During this investigation, the Department of Social Services Investigation Bureau Investigator conducted the following: interviewed R-1’s Placement Agency, Facility Administrator, Staff #1 through Staff #5 (S-1 through S-5) and obtained relevant documentation for R-1. R-1 was unable to be interviewed as R-1 is visually impaired and non-verbal. Refer to LIC 9099-C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

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-20210707164610

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 AND M IV HOME CARE	FACILITY NUMBER: 198601772
	VISIT DATE: 04/27/2022

NARRATIVE

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Allegation: Staff neglect resulting in resident being malnourished. During this investigation, the Department of Social Services Investigation Bureau Investigator interviewed R-1’s Placement Agency,
Facility Administrator, Staff #1 through Staff #5 (S-1 through S-5) and obtained relevant documentation for R-1. Per Investigator, there was insufficient evidence to determine that facility staff failed to provide adequate care for R-1. Per Investigator, facility staff provided feeding logs and were also in constant communication with R-1’s Physician and Placement Agency overall R-1’s health. Additionally, per Investigator, the Placement Agency indicated the facility provided care for R-1 and followed R-1’s health plan. R-1 was also offered continuously all R-1’s medication, food and liquid intake. R-1 was transferred to another facility as R-1 required a higher level of care. Interviews and obtained documentation do not corroborate this allegation.
Allegation: Resident suffered from dehydration while in care. During this investigation, the Department of Social Services Investigation Bureau Investigator interviewed R-1’s Placement Agency, Facility Administrator, Staff #1 through Staff #5 (S-1 through S-5) and obtained relevant documentation for R-1. Per Investigator, there was insufficient evidence to determine that facility staff failed to provide adequate care for R-1. Per Investigator, facility staff provided feeding logs and were also in constant communication with R-1’s Physician and Placement Agency overall R-1’s health. Additionally, per Investigator, the Placement Agency indicated the facility provided care for R-1 and followed R-1’s health plan. R-1 was also offered continuously all R-1’s medication, food and liquid intake. R-1 was transferred to another facility as R-1 required a higher level of care. Interviews and obtained documentation do not corroborate this allegation.
Allegation: Resident developed a UTI infection while in care. During this investigation, the Department of Social Services Investigation Bureau Investigator interviewed R-1’s Placement Agency, Facility Administrator, Staff #1 through Staff #5 (S-1 through S-5) and obtained relevant documentation for R-1. Per Investigator, there was insufficient evidence to determine that facility staff failed to provide adequate care for R-1. Per Investigator, facility staff were in constant communication with R-1’s Physician and Placement Agency overall R-1’s health. Additionally, per Investigator, the Placement Agency indicated the facility provided care for R-1 and followed R-1’s health plan. Interviews and obtained documentation do not corroborate this allegation.

Although the allegations 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.
Exit interview was conducted, a copy of this report and Appeal Rights were provided to Mona De La Rosa_.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC9099 (FAS) - (06/04)

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