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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601815
Report Date: 11/04/2021
Date Signed: 11/04/2021 09:06:11 AM

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
04/26/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210426093119
FACILITY NAME:ALFORD HOMEFACILITY NUMBER:
198601815
ADMINISTRATOR:SEAN ESTRELLAFACILITY TYPE:
734
ADDRESS:165 ALFORD STTELEPHONE:
(909) 599-7403
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:5CENSUS: 2DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Cheevey Gesite, RNTIME COMPLETED:
09:20 AM
ALLEGATION(S):
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Staff did not seek medical treatment for client on a timely basis.
Staff did not meet client's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to deliver findings for the allegations listed above. LPA met with Cheevey Gesite, Registered Nurse (RN) and explained the reason for the visit. The initial complaint visit was conducted by LPA Vasallo on 4/26/21. Investigator, Edward Hector conducted additional visits.

The investigation consisted of the following: Client #1’s (C1’s) file was reviewed, and the following was obtained: Physician's report, admission agreement, incident reports, Individual Health Care Plan (IHCP), wound documents, C1's emergency contact, Medication Administration Record (MAR), and Respiratory Therapist (RT) information. C1’s medical records and San Gabriel/Pomona Regional Center documents were also reviewed. Interviews were conducted with facility staff, regional center staff, and medical professionals that treated C1.

The investigation revealed the following: Allegation: Staff did not seek medical treatment in a timely basis. Client was admitted to the facility on 8/27/20 and there were no wounds noted. On 9/3/20, client went to the hospital for a UTI. Client returned to the facility on 9/18/20 with two open wounds. Continued on 9099C.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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 5
Control Number 28-AS-20210426093119
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: ALFORD HOME
FACILITY NUMBER: 198601815
VISIT DATE: 11/04/2021
NARRATIVE
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On 9/23/20, client was diagnosed with two Stage 3 wounds. On 10/5/20, Department of Developmental Services (DDS) and regional center approved the support letters for treatment of client’s wounds at the facility. From 9/18/20 – 9/23/20 client did not obtain care for the wounds because there was no official diagnosis and there was no treatment plan. Therefore, facility delayed medical treatment to client for 5 days. Based on the information obtained, the allegation is substantiated.

Allegation: Staff did not meet client's needs. C1 had ongoing issues with his/her bladder and constant urination. The use of a Purewick system, which is a urine collection system that works outside the body and helps keep the skin dry, was discussed with the facility. There were financial barriers and there was an insurance process to go through. The facility never obtained the Purewick system which could have assisted C1’s skin to repair quicker. Also, C1 had a broken wheelchair for months which facility never had repaired. This caused C1 to spend the majority of time in bed. Facility staff reported that COVID-19 caused the delay in obtaining these items. Based on the information obtained, the allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.



Exit interview held. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20210426093119
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: ALFORD HOME
FACILITY NUMBER: 198601815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited
CCR
80072(a)(2)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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C1 no longer lives at the facility. Facility will certify that all clients needs will be met and will document what steps will be taken. Plan due by 11/5/21.
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Deficiency was evidenced by the following:
Facility did not advocate enough for C1’s Purewick system which could have helped repair C1’s skin. C1’s wheelchair was broken for months and facility never repaired it.
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Type A
11/05/2021
Section Cited
CCR
80072(a)(9)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (9) To receive or reject medical care, or health-related services, except for minors and other clients for whom a guardian, conservator, or other legal authority has been appointed.
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Facility will certify that all clients needs will be met including pressure injuries. Facility will submit plan to address pressure injuries in a timely manner. Plan due by 11/5/21.
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Deficiency was evidenced by the following:
On 9/18/20, C1 returned to facility with two open wounds. On 9/23/20, client was diagnosed with two Stage 3 wounds. From 9/18/20 – 9/23/20 client did not obtain care for the wounds while at the facility. Facility delayed medical treatment to client for 5 days.
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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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/26/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210426093119

FACILITY NAME:ALFORD HOMEFACILITY NUMBER:
198601815
ADMINISTRATOR:SEAN ESTRELLAFACILITY TYPE:
734
ADDRESS:165 ALFORD STTELEPHONE:
(909) 599-7403
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:5CENSUS: 2DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Cheevey Gesite, RNTIME COMPLETED:
09:20 AM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Client sustained Stage 4 pressure injury while in care.
INVESTIGATION FINDINGS:
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5
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10
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12
13
Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to deliver findings for the allegations listed above. LPA met with Cheevey Gesite, Registered Nurse (RN) and explained the reason for the visit. The initial complaint visit was conducted by LPA Vasallo on 4/26/21. Investigator, Edward Hector conducted additional visits.

The investigation consisted of the following: Client #1’s (C1’s) file was reviewed, and the following was obtained: Physician's report, admission agreement, incident reports, Individual Health Care Plan (IHCP), wound documents, C1's emergency contact, Medication Administration Record (MAR), and Respiratory Therapist (RT) information. C1’s medical records and San Gabriel/Pomona Regional Center documents were also reviewed. Interviews were conducted with facility staff, regional center staff, and medical professionals that treated C1.

The investigation revealed the following: Medical records and staff interviews confirm C1 did have multiple Stage 3 wounds while living at the facility. On 9/3/20, client went to the hospital for a UTI. On 9/18/20, client returned to the facility with two Stage 3 wounds. Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210426093119
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: ALFORD HOME
FACILITY NUMBER: 198601815
VISIT DATE: 11/04/2021
NARRATIVE
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The facility obtained support letters from Department of Developmental Services (DDS) and regional center to care for the wounds without relocating the client. C1's wound care specialist and primary physician indicated the facility provided great care to C1 and there were no concerns. C1 had multiple health issues and was in poor health. Regional center’s investigation report was reviewed and there was no mention that facility staff caused C1’s wounds. Based on the information obtained, the allegation is unsubstantiated.

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 held. A copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5