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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601815
Report Date: 10/21/2024
Date Signed: 10/21/2024 11:44:44 AM

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
07/01/2024 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20240701085954
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: 4DATE:
10/21/2024
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Administrator Matthew MailangkayTIME COMPLETED:
11:59 AM
ALLEGATION(S):
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Staff are inapporpriately touching resident
Staff are not providing a comfortable environment for resident
Staff are sleeping during there shift
INVESTIGATION FINDINGS:
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On 10/21/2024 Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent visit to investigate the above allegations. LPA met with Lillie Escobar, Registered Nurse and discussed the purpose of today's visit. The Administrator Matthew Mailangkay was there upon arrival and LPA explained the reason for the visit.

During the initial visit, LPA Baptiste obtained a copy of the Resident roster, staff roster, R1’s Medication administration record (MAR) for 1 month, R2’s Medication administration record (MAR) for 1 month, and buddy system checks for 1 month. LPA interviewed the administrator and a total of 4 staff who shall be referred to as S3 through S6. There is a total of 4 residents, but due to their limited communication, LPA was only able to use the interview for 1 resident. The resident shall be known as R4. LPA Baptiste also reviewed medications for all residents with the administrator and reviewed staff files for S1 and S2.

Report continued on 9099c
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
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-20240701085954
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: 10/21/2024
NARRATIVE
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Prior to the visit LPA attempted to contact the San Gabriel Pomona Regional Center. LPA interviewed 4 staff who shall be referred to as S1, S2, S7 and S8. LPA also interviewed a former staff who shall be referred to as W1. LPA received photos of the G-tube dressing for Resident #2.

During today’s visit LPA was informed S1 no longer works at the facility for personal reasons. LPA attempted to interview R3 with S3 as a translator. Unfortunately, LPA could not use interview due to the resident’s medical diagnosis.

The investigation reveals the following: " Staff are inappropriately touching resident”. It is alleged that S1 tickles and aggravates R3. During the visit, the Administrator stated R3 will state if they are bothered by S1. The Administrator further stated they have not heard S1 aggravates R3. 5 out of 8 staff stated they have not seen staff touch the residents inappropriately. 2 out of 8 staff stated that S1 hugs R3 and sometimes R3 like it and sometimes they don’t. 1 out of 8 staff stated R3 do not like S1 to touch their hair. W1 stated R1 annoys S3. 1 out of 1 resident stated staff do not touch them inappropriately nor have they witness staff touching the other residents inappropriately. LPA attempted to interview R3 but could not use their interviews.



The investigation reveals the following: " Staff are not providing a comfortable environment for resident”. It is alleged that the facility is not providing a comfortable environment for the residents. During the visit, the Administrator denied the allegation stating none of the residents complained of being uncomfortable. 8 out of 8 staff stated the residents live in a comfortable Environment. 2 out of 2 residents confirmed they live in a comfortable environment.

The investigation reveals the following: " Staff are sleep during their shift.”. It is alleged that staff sleeps in R2’s bedroom. During the visit, the Administrator denied the allegation stating they have not seen or heard that staff sleep in the resident’s bedrooms. 6 out 8 staff stated they have not seen staff sleep in the resident’s room. 2 out of 8 staff stated R1 was caught sleeping in the resident’s room or they have seen R1’s sleep in the resident’s room. W1 stated they have heard R1 sleeps on R2’s recliner. 1 out of 1 resident confirmed they have never seen staff sleeping during their shift. LPA conducted file review and did not observe disciplinary actions related to staff sleeping during their shift.



there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the
allegation is UNSUBSTANTIATED.

Exit Interview Conducted with Registered Nurse Lillie Escobar/ A Copy of the Report Issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 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
07/01/2024 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20240701085954

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: 4DATE:
10/21/2024
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Administrator Matthew MailangkayTIME COMPLETED:
11:59 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are mismanaging residents medication
Staff are not properly caring for resident's G-tube
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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9
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13
On 10/21/2024 Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent visit to investigate the above allegations. LPA met with Lillie Escobar, Registered Nurse and discussed the purpose of today's visit. The Administrator Matthew Mailangkay was there upon arrival and LPA explained the reason for the visit.

During the initial visit, LPA Baptiste obtained a copy of the Resident roster, staff roster, R1’s Medication administration record (MAR) for 1 month, R2’s Medication administration record (MAR) for 1 month, and buddy system checks for 1 month. LPA interviewed the administrator and a total of 4 staff who shall be referred to as S3 through S6. There is a total of 4 residents, but due to their limited communication, LPA was only able to use the interview for 1 resident. The resident shall be known as R4. LPA Baptiste also reviewed medications for all residents with the administrator and reviewed staff files for S1 and S2.

Report continued on 9099c
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
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 5
Control Number 28-AS-20240701085954
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: 10/21/2024
NARRATIVE
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The investigation reveals the following: " Staff are mismanaging residents’ medication”. It is alleged that S1 is not providing medications to residents, and staff are not hydrating the residents. During the visit, the Administrator denied the allegation stating staff has provided medications and hydration. The Administrator further stated the facility has a buddy check system to limit errors. 7 out of 8 staff stated residents are hydrated and given their medications. 1 out of 8 staff stated S1 checks off on the MAR that they have given medications and hydration, but do not provide the medications or hydration to the residents. W1 state S1 do not provide medications or hydration to the residents. 1 out of 1 resident confirmed staff provides their medications with no issues. LPA Baptiste reviewed the MAR dated Jun 2024 for R2 and observed on June 1st and June 12th hydration was not checked as completed on the MAR.

The investigation reveals the following: " Staff are not properly caring for resident's G-tube”. It is alleged that S1 marks that R1 dressing has been change for their G-tube, but staff are able to observe that the dressing has not been changed. During the visit, the Administrator denied the allegation, stating R1’s dressing is changed every shift, with the date and the time written on the gauze. 3 out of 8 staff confirmed staff changes R1’s dressing every shift. 4 out of 8 confirmed they have come into worked and observed old dressings. 1 out of 8 staff was unsure if staff changed the dressing of R1 every shift. W1 stated that staff forgets to change R1’s dressing. LPA received a photo of R1’s unchanged gauze. W1 stated the dressing was there for 24 hours. Per R1’s MAR the dressing is changed every shift.

Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.

Exit Interview Conducted with Registered Nurse Lillie Escobar / Appeal Rights Provided / A Copy of the Report Issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240701085954
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: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2024
Section Cited
CCR
80075(b)
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80075 - Health Related Services.
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Administrator will train staff members on medication procedures. A training for all shifts will be conducted. The sign in sheet with the topic of the training will be submitted to LPA by 10/22/2024. LPA is
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R2 medication records had mutliple days that staff did not sign. Staff interviews and photo observation for R1 showed staff was not changing residents dressing every shift, which poses an immediate health, safety or personal rights risk to persons in care.
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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: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5