198602364-7-9-2023-28-AS-RORN-CTULGF-20230718084437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602364
Report Date: 07/09/2023
Date Signed: 07/09/2023 12:17:59 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
04/06/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220406140042

FACILITY NAME:	CN HOME 2		FACILITY NUMBER:	198602364
ADMINISTRATOR:	MATHARU, ANITA		FACILITY TYPE:	735
ADDRESS:	14516 PIONEER BLVD		TELEPHONE:	(310) 612-0978
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	4	CENSUS: 4	DATE:	07/09/2023
		UNANNOUNCED	TIME BEGAN:	11:24 AM
MET WITH:	Veronica Flores - DSP		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Client sustained fracture while in care.
Staff did not seek timely medical care for client in care.

INVESTIGATION FINDINGS:

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**Please note: This facility report will supersede the report dated 05/25/22, to include additional information following the investigation conducted by the licensing Investigation Branch. However, the findings of the allegations will not change.**

Licensing Program Analyst (LPA) Mora made an unannounced visit at the facility for the purpose of delivering a superseded report. LPA Mora met with Veronica Flores and explained the purpose of the visit.

On 5/25/22, Licensing Program Analyst (LPA) Nicole Wesley initiated a complaint investigation for the allegations listed above. LPA Wesley interviewed the Administrator, staff, attempted to interview clien#1 (C1), other parties, and requested a copy of the staff roster, resident roster, hospital discharge papers from visit on 03/21/22, current medication list, ID page (facesheet), current physician report, and current IPP.

(Continued LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2023

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-20220406140042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CN HOME 2	FACILITY NUMBER: 198602364
	VISIT DATE: 07/09/2023

NARRATIVE

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The investigation was assigned to Investigation’s Branch (IB) Investigator, Laura Garcia, badge# 225. IB investigator Garcia's investigation consisted of the following: interviews conducted with facility staff#1-4 (S1-S4),C1's relative (CR1), Client#2's relatives #1-2 (CR2-CR3), C1's Service Coordinator (SC), and attempted to interview C1'S physician. IB investigator Garcia also attempted to obtain a copy of hospital medical records, but was unsuccessful without response. C1 was not interviewed due to being non-verbal.
Regarding allegation: Client sustained fracture while in care.
It is alleged that Client#1 (C1) had a medical emergency that resulted in C1 almost falling off the bed and pushed onto the bed by staff to prevent the fall. This resulted in C1 sustaining a fracture. Through interviews conducted with S1-S4, it was noted that the allegation was denied and C1 did not almost fall off the bed. It was stated that on 3/31/22, C1 had a medical emergency at the facility. Upon C1 suffering the medical emergency, staff stayed with C1 until it passed and conducted a body check after that determined C1 was okay. It was discovered through the placement agency's notes that C1's hospital scans revealed C1 suffered from a brittle bone condition. Per interview with CR1, CR1 stated C1's physician advised that C1 is susceptible to injury due to this condition and may have not been related to the "fall" C1 allegedly had at the facility. IB Investigator deemed this allegation to be Unsubstantiated.
Regarding allegation: Staff did not seek timely medical care for client in care.
It is alleged that C1 suffered a medical emergency at the facility that resulted in a fracture an facility staff failed to seek medical care for C1 in a timely manner, though C1 was in pain. Through interviews conducted with S1-S4, it was noted that the allegation was denied. It was stated that on 3/31/22, C1 had a medical emergency at the facility. Upon C1 suffering the medical emergency, staff stayed with C1 until it passed and conducted a body check after. The following day, 4/01/22, C1 was evaluated by S2 and appeared to be fine. C1 went about their day as usual and attended day program. On 4/02/23, S4 noticed that C1 expressed pain and discomfort through grimacing facial expressions. S2 was notified right away and advised to send C1 to the hospital for further evaluation. S1-S4 stated that all events leading to C1 being taken to the hospital were documented and reported right away to CR1, the Licensing Agency, and to C1's SC. IB Investigator Garcia deemed this allegation to be 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.

Per California Code of Regulations, Title 22, no deficiencies were cited or observed.
An exit interview was conducted with Veronica Flores and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2023

LIC9099 (FAS) - (06/04)

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