198601841-5-6-2022-28-AS-MVAO-CEJU6N-20220518151837

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601841
Report Date: 05/06/2022
Date Signed: 05/06/2022 11:48:36 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
12/02/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211202162824

FACILITY NAME:	DEVLIN FACILITY		FACILITY NUMBER:	198601841
ADMINISTRATOR:	LA MARR, KEISHA		FACILITY TYPE:	735
ADDRESS:	20516 DEVLIN AVE		TELEPHONE:	(562) 278-2127
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90715
CAPACITY:	3	CENSUS: 3	DATE:	05/06/2022
		UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Administrator, Baltazar Cornego		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

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Client developed a pressure injury while in care
Insufficient staffing to meet client needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit. The initial complaint visit was conducted by LPA Nina Galarza on 12/9/21. LPA met with Administrator, Baltazar Cornego and explained the reason for the visit.

The investigation consisted of the following: LPA Galarza interviewed 3 staff and reviewed client and staff records. LPA Galarza obtained copies of the staff and client roster, recent physicians reports for clients repositioning log for Client #1 (C1), and program plan. LPA Galarza was unable to interview Clients due to communication barriers. LPA Vasallo reviewed C1's Individual Program Plan (IPP) quarterly regional center report, and repositioning log. Interviews were conducted with 4 staff, C1's wound care nurse and representative from Harbor Regional Center.
The investigation revealed the following: It's alleged a client has developed a pressure injury while in care. C1's IPP dated 10/26/21 indicates C1 has a history of skin integrity issues. C1 has a restricted health care plan on file for pressure injuries. 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: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

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-20211202162824

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: DEVLIN FACILITY	FACILITY NUMBER: 198601841
	VISIT DATE: 05/06/2022

NARRATIVE

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C1's quarterly report from Harbor Regional Center dated 2/7/22 indicates C1 has a reoccurring Stage 1 ulcer on his/her bottom from insufficient circulation to the area. Wound care nurse from Excellence Home Health indicated C1 had 2 pressure injuries on the buttock. One of the wounds has healed and the other wound is healing well. Repositioning logs were reviewed and go back as far as April 2021. It's documented that C1 is repositioned regularly. Staff also confirmed C1 is repositioned every 2 hours and C1's wound is healing well. Regional center representative did not have any concerns about the wounds and confirmed home health visits C1 regularly. There is insufficient evidence to prove the pressure injury developed due to neglect. Therefore, this allegation is unsubstantiated.

It's also alleged facility has insufficient staffing. The facility program plan requires the facility to have 2 staff in the morning, 2 staff in the afternoon, and 1 overnight staff. 6 out of the 7 staff interviewed indicated there is sufficient staff and they are meeting the required ratios. Regional center staff did not have any information about shortage of staff. Clients are unable to answer questions during interview and therefore cannot confirm the allegation. The staff schedule indicates all shifts are covered appropriately. Based on the information obtained, the allegation is unsubstantiated.

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 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: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

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