198602255-3-30-2022-11-AS-MVAO-CDQSYB-20220422141716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602255
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:48:56 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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220323095626

FACILITY NAME:	CALIFORNIA MENTOR - DOMINGUEZ HOME		FACILITY NUMBER:	198602255
ADMINISTRATOR:	ROSAS, CLAUDIO		FACILITY TYPE:	735
ADDRESS:	214 E DOMINGUEZ		TELEPHONE:	(909) 483-2505
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	3	CENSUS: 3	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Clauido Rosas, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff refused to administrate glucose testing per doctors orders.
Facility staff is not ensuring that the resident is receiving timely medication administration.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Claudio Rosas, the facility administrator.

The investigation consisted of following: Interviews and Record reviews. On 03/30/22, LPA Soto interviewed Administrator, Jeri Miles - Area Director, Brian Lockhart - Regional Director, S#4, Glady's Njuguna - RN, C#1, and C#2. LPA Soto received the following documents: Resident Roster, Staff Schedule, Face sheet, SCB counseling Evalution, Admissions agreement, Conservator, Regional Center Quarterlyt report, Mar's (February and March 2022) Care Plan, Blood sugar readings, Staff trainings, Doctor's new order, copy of receipt for glucose machine, and Lab results.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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 11-AS-20220323095626

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - DOMINGUEZ HOME	FACILITY NUMBER: 198602255
	VISIT DATE: 03/30/2022

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following.

For Allegation 1 – Staff refused to administrate glucose testing per doctors orders. Interviews with Administrator, Area Director, Regional Director, RN, and S#4 all stated that they did not refuse, they were not sure that CCLD regulations would allow the staff to perform that task. When the Facility received the doctor's orders on 03/22/22,They were awaiting for the glucose machine to be sent by the pharmacy, but it did not arrive. On 03/23/22 the Area Director purchased one for C#1 on 03/23/22. The RN began to take the glucose reading for C#1 on 03/23/22 based on having machine and glucose log for C#1. The Administrator, Area Director, and Regional Director did their due diligence to research and clarify, if it was in the regulations, that staff could perform the glucose drawings. When they knew the staff could perform that task as long the staff was trained by a medical professional, the RN began to perform training for all the staff. The training began from 03/25/22 - 03/28/22, based on the training logs. Interviews with C#1 & C#2, were not possible because of clients mental condition they could communicate with LPA. The interviews and records reviewed did not concur with the above allegation.

Allegation 2 - Facility staff is not ensuring that the resident is receiving timely medication administration. Interviews with Administrator, Area Director, Regional Director, S#4, and RN, all stated that the medications are being given in a timely manner. There was an error before, but It was already investigated and resolved in February 2022. LPA Soto reviewed the Mar's for February and March 2022, R#1 medication are being administered and prescribed by Doctor's orders. Interviews with C#1 and C#2, were not possible because of their mental condition they could not communicate with LPA. the interviews and records reviewed did not concur with the above allegation.

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

An exit interview was conducted with Claudio Rosas, Administrator, and a hard copy of report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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