198602183-6-13-2023-28-AS-RORN-CT2VHG-20230622162703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602183
Report Date: 06/13/2023
Date Signed: 06/13/2023 02:09:05 PM

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
06/05/2023 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230605113509

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: 5	DATE:	06/13/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrator Vilma Bohanan		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff left resident soiled in urine for an extended period of time
Resident is being charged for supplies not agreed upon in the Admission Agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint investigation visit for the allegation(s) above. LPA met with Administrator Vilma Bohanan and the purpose of the visit was discussed.

On todays visit LPA conducted the following: LPA toured the physical plant , Interviewed residents #1-#4 (R1-R4), R2's authorized representative (AR1) and staff #1-#4 (S1-S4). LPA reviewed and collected the following documents from R'1's file: Facesheet , Admissions agreement , Physicians report, and the Needs and Services care plan. LPA also received a copy of the facilities staff and resident roster. The investigation revealed the following:

In regards to the allegation "Staff left resident soiled in urine for an extended period of time" it was alleged that R1 would be left in urine filled diapers for an extended period of time. (4) of (4) Staff interviewed denied the allegation. (4) of (4) Residents interviewed could not corroborate the allegation...
CONTINUED ON LIC 9099-C

Unsubstantiated

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: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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-20230605113509

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: 06/13/2023

NARRATIVE

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Interviews show that R1 is changed at least 3 times a day and does not request staff for further diaper changes. File review does not specify how many diaper changes a resident may receive but does show R1 requires assistance with toileting needs. R1 confirmed they do not ask for more diaper change throughout the day than the amount of times they are already assisted for. LPA did not observe odor of urine in the facility. Based on interviews, file review and observations; 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.

In regards to the allegation "Resident is being charged for supplies not agreed upon in the Admission Agreement" it is alleged that the facility charges R1 for items that were not agreed upon during admission. (4) of (4) Staff interviewed denied the allegation. (4) of (4) Residents interviewed could not corroborate the allegation. Interview with S1 states that residents are informed that diapers are part of incontinence care and are charged separately from basic needs and services. Everyone who is admitted to the facility understands this and responsible parties are also aware of it. This means that if at some point , residents prefer diapers or needs incontinence care, they can pay for them personally and staff will assist with changing as part of their toileting needs but they are not provided by the facility unless agreed upon admission. Interview with AR1 confirms this information. Review of R1's file does not show that they are receiving incontinence care and paying for diapers as part of their agreement. R1 confirmed that they have a preference of specific diapers and pads separate from the ones provided by the facility and so R1 purchases those themselves. Based on interviews, file review and observations; 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 conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC9099 (FAS) - (06/04)

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