198602183-11-18-2020-28-AS-FFIS-C693BE-20210825180610

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602183
Report Date: 11/16/2020
Date Signed: 11/18/2020 12:15:43 PM

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
11/09/2020 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201109130517

FACILITY NAME:	JORDAN GUEST HOME		FACILITY NUMBER:	198602183
ADMINISTRATOR:	BOHANAN, VILMA TRAZO		FACILITY TYPE:	740
ADDRESS:	10657 JORDAN ROAD		TELEPHONE:	(562) 822-4677
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	6	CENSUS: 6	DATE:	11/16/2020
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Vilma Bohanan		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff are not meeting a resident's daily transfer needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted an initial 10-Day complaint visit regarding the above allegation, and delivered findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Vilma Bohanan

The investigation consisted of the following: LPA interviewed Resident #1 (R1), Administrator and Staff #1 (S1). LPA reviewed and collected documents from R1's file which included; physicians report, needs and services plan, admissions agreement, and preplacement appraisal information.

The investigation revealed the following: Regarding the allegation "Facility staff are not meeting a resident's daily transfer needs" it was alleged that R1 was not receiving assistance out of bed daily by S1...

Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

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-20201109130517

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: JORDAN GUEST HOME	FACILITY NUMBER: 198602183
	VISIT DATE: 11/16/2020

NARRATIVE

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Based on files reviewed, R1's needs & services plan as well as the physicians report show that R1 is non-ambulatory and requires assistance to get in and out of bed. Interviews conducted show that S1 has not been aiding R1 out of bed daily but instead every other day. On the days that S1 does not aid R1, R1 texts the administrator and then waits for the administrator Vilma to arrive at the facility to help R1 out of bed. This shows that the facility staff failed to meet the necessary needs and services of R1 because up until the administrator arrives, there is no staff at the facility that is providing R1 assistance out of bed.

Based on review of documents and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D.

Exit interview was conducted with Administrator Vilma Bohanan. A copy of the report was emailed to Vilma for signature. Appeal rights were discussed and given to administrator.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20201109130517

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: JORDAN GUEST HOME	FACILITY NUMBER: 198602183
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 11/23/2020 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed upon a change in staffing schedule so that someone else besides S1 will be available to aid R1 in and out of bed. Updated staff schedule and roster to be sent into Licensing by POC due date.
	8 9 10 11 12 13 14	Interviews show that R1 would not recieve assistance out of bed daily by S1 and would have to wait until Adminstrator arrived to get assistance. This poses a potential health and safety risk to residents in care and supervision.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

LIC9099 (FAS) - (06/04)

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