198601772-9-26-2024-28-AS-TVAO-D9ULP6-20241008085523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601772
Report Date: 09/26/2024
Date Signed: 09/26/2024 04:13:12 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
09/25/2024 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240925144616

FACILITY NAME:	A AND M IV HOME CARE		FACILITY NUMBER:	198601772
ADMINISTRATOR:	LADY ROXANNE ARCIBAL		FACILITY TYPE:	735
ADDRESS:	226 E. ANNAPOLIS DRIVE		TELEPHONE:	(909) 618-7064
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	4	CENSUS: 3	DATE:	09/26/2024
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Administrator Ana Alarcio		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not prevent a client from accessing illegal drugs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Health & Safety check on 09/26/2024 regarding the above allegation. LPA Ramirez was Direct Support Staff Angelica Naungayan and explained the purpose of the visit. Administrator Ana Alarcio and Licensee Mona dela Rosa arrived shortly after to assist with tour.
The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 3 interviews (S1 – S3), Attempted interview of Client#1 (C1), Interviews of Client#2-3 (C2-C3), Attempted interview of Claremont Police Corporal Jacob Tillamn, copies of Client#1 (C1) Physician’s Report, Individual Program Plan (IPP) dated 07/22/2024, physician’s order dated 09/24/24, C1's Medication Administration Record from 08/2024 through 09/25/24, summary of doctor’s visit dated 09/24/24, Pomona Valley Hospital Medical Center discharge instructions dated 09/23/24 and physical plant tour.

See 9099-C for continued narrative

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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-20240925144616

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 IV HOME CARE	FACILITY NUMBER: 198601772
	VISIT DATE: 09/26/2024

NARRATIVE

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The investigation revealed the following. Regarding Allegation: Staff did not prevent client from accessing illegal drugs- It is alleged that staff did not prevent C1 from accessing illegal drugs. On 09/23/24, C1 was taken to urgent care with symptoms of a runny nose and slight cough. After examination and labs ordered by the hospital, it was revealed C1 tested positive for PCP (Phenyl cyclohexyl piperidine) and amphetamines. C1 was treated for symptoms and released back to the facility on 09/23/24. C1 is ambulatory, non-verbal, has a severe vision impairment and has cognitive impairments. C1 has a physician’s order for chlorpromazine and clonazepam. Physician’s order dated 09/24/24, revealed C1’s recent positive testing (09/23/24) for PCP and amphetamines, was due to C1’s prescription of chlorpromazine and clonazepam. During health & safety check on 09/26/24, LPA Ramirez observed C1 to be well groomed, dressed appropriately, and well nourished. LPA Ramirez toured facility and did not observe any immediate health & safety violations. On 09/23/24, Corporal Jacob Tillman with the Claremont Police Department, came to the facility to investigate the above allegation. Per Administrator Ana Alarcio, Corporal Tillman did not finding evidence of a crime and left a citizen contact card as reference. LPA Ramirez contacted Corporal Tillman and left a message requesting a callback. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three (3) clients interviewed deny this allegation. 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.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC9099 (FAS) - (06/04)

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