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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601772
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:58:27 PM

Substantiated


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
03/29/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210329084734
FACILITY NAME:A AND M IV HOME CAREFACILITY NUMBER:
198601772
ADMINISTRATOR:ARIEL P. DELA ROSAFACILITY TYPE:
735
ADDRESS:226 E. ANNAPOLIS DRIVETELEPHONE:
(909) 618-7064
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:4CENSUS: 3DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mona Dela Rosa TIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Client sustained multiple pressure injuries while in care
Staff did not complete medical follow up for a client while in care

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted another visit, to issue the final results of the investigation. LPA met with Administrator, Ana Alarcio who assisted with today's visit. Licensee, Mona De La Rosa arrived at the facility a short time later.

Regarding the allegation that (1) Client #1 sustained multiple pressure injuries while in care, and (2) Staff did not complete medical follow up for a client while in care: The investigation was conducted by the department, which included interviews with staff, residents, and review of client #1's facility file and hospital records. The investigation revealed the following : Previous administrator, Roberto Ronas stated that on 10/22/2020 facility staff notified him that Client #1 had a pressure sore on his right hip. Administrator stated that he did not contact Client #1's primary care physician (PCP) until approximately eight days later. Administrator stated that he instructed facility staff to implement basic first aid care on Client #1. When Client #1's wound did not improve, Administrator contacted Client #1's PCP for treatment for Client #1.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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 4
Control Number 28-AS-20210329084734
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: 10/19/2023
NARRATIVE
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On 11/26/2020, Client #1's PCP referred Home Health nurse to go to facility to check on Client #1. On 1/08/2021, facility staff reported to Administrator that Client #1 had a pressure sore on his left shoulder. Administrator admitted that PCP was not contacted, and facility only implemented first aid care for Client #1.

On 2/13/21, Client #1’s PCP conducted an onsite medical check on Client #1, and found a pressure sore on Client #1’s left hip and left deltoid. Administrator, did not contact PCP prior to the visit regarding pressure sores.

On 3/4/21, Administrator reported to the regional center that there were two stage III pressure sores on Client #1’s middle back and left shoulder. On 3/9/21, Client #1 was taken to a skilled nursing facility for treatment and was diagnosed with four stage III pressure sores on left shoulder, middle back, and left and right hips. Administrator admitted to failing to implement medical care in a timely manner, when staff notified him of Client #’1s pressure sores.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 Division 6, Chapter 1.



Immediate Civil Penalty will be issued in the amount of $500.00

"The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e)or (f), or 1548 (e) or (f), 1568.0822(e) or (f)."

An exit interview was conducted with Ms.De La Rosa. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
03/29/2021 and conducted by Evaluator Angelica Rea
COMPLAINT CONTROL NUMBER: 28-AS-20210329084734

FACILITY NAME:A AND M IV HOME CAREFACILITY NUMBER:
198601772
ADMINISTRATOR:ARIEL P. DELA ROSAFACILITY TYPE:
735
ADDRESS:226 E. ANNAPOLIS DRIVETELEPHONE:
(909) 618-7064
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:4CENSUS: 3DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ana AlarcioTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Client sustained injuries from falls while in care
INVESTIGATION FINDINGS:
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Regarding the allegation that Client #1 sustained injuries from falls while in care, the investigation included interviews with Licensee, staff #1, staff #2, resident(s), and review of client #1's facility file. Staff and resident(s) interviewed stated that client #1 engaged in self -injurious behaviors which included "throwing himself off of the bed, and on to the floor". Staff interviewed stated that staff would try to prevent Client #1 from injuring himself, whenever he exhibited those behaviors. Client #1's Individual Program Plan dated 1/28/21 states that client engages in self injurious behaviors. Client #1 is no longer living at the facility and was unable to be interviewed.

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 was conducted with Ana Alarcio and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20210329084734
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2023
Section Cited
CCR
80091(a)(4)
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(a) In adult CCFs clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained. (4) Stage 3 and 4 dermal ulcers. This requirement was not met as evidenced by : Client #1 was admitted to skilled nursing facility on 3/9/21 with
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Licensee will ensure that the facility abides by Title 22 regulations, and does not retain resident(s) with prohibited health conditions. LIcensee will conduct an in service training with staff on Section 80091, and will provide LPA with proof of training by POC date.
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four stage III pressure sores on his left shoulder, middle back, and left and right hips. This poses an immediate health, safety, or personal rights risk to persons in care.
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Type A
10/23/2023
Section Cited
CCR
80075(a)
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(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.
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Facility is to ensure that Title 22 Section 80075 regulations are met at all times. Additionally, an in-service training is to be conducted regarding Title 22 Section 80075 and a training log with staff signature submitted to CCLD by POC due date.
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This requirement is not met by:
Based on interviews and records review, the Administrator did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Facility did not ensure that client #1 received timely medical care for pressure sores that were oberved and reported to administrator by staff.
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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: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4