198602375-10-12-2021-11-AS-JHAD-C82RDC-20211022125540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602375
Report Date: 10/12/2021
Date Signed: 10/12/2021 03:15:17 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
09/01/2021 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210901145313

FACILITY NAME:	ROSTAR HOME II INC		FACILITY NUMBER:	198602375
ADMINISTRATOR:	THENG, THANA		FACILITY TYPE:	735
ADDRESS:	1527 WEST 247TH PLACE		TELEPHONE:	(310) 326-1746
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	4	CENSUS: 4	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Thana Theng, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are mismanaging residents medication
Staff did not ensure resident was seen by a physician

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Thana Theng, the facility administrator.

The investigation consisted of following: Interviews and Record reviews. On 09/09/21, LPA Soto interviewed Thana Theng, Administrator, S#2, C#1 – C#4. LPA Soto toured the entire facility with Elsy. The LPA also requested copies of the following documents: Face sheets, Mars (August & September 2021,) Physician's Report, Appraisal Needs and Services Plan, and IPP for C#1.

Based on the LPA's investigation, the investigation revealed the following. For Allegation 1 - Staff are mismanaging residents’ medication. Interviews with S1 and Administrator stated that C1’s Psychiatrist retired in July 2021. They have been trying to get a new doctor for C1, it will take a few weeks to get a new doctor assigned by the insurance company

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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-20210901145313

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: ROSTAR HOME II INC	FACILITY NUMBER: 198602375
	VISIT DATE: 10/12/2021

NARRATIVE

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The reason C1 had an aggressive behavior was not because of C1 medication, but because another client irritated C1 with their constant talking. LPA Soto reviewed C1’s records and they revealed C1 medication had been administered as prescribed. C1 has been doing good in the last couple of weeks according to S2 and administrator. C1 taking the same medications and doing well just like C1 has always been doing. C1 does not have any aggressive behaviors, C1 is usually very happy and smiles all the time, it seems that the aggressive behavior was very unusual for C1. Interviews with C1 – C3, could not communicate with LPA Soto. Interview with C4 stated that C1 always screams, but C4 does not know why. Interviews conducted and records reviewed do not concur with the above allegation.

Allegation #2 – Staff did not ensure resident was seen by a physician. Interviews with S1 and Administrator stated that C1’s Psychiatrist retired in July 2021. They have been trying to get a new doctor for C1, it will take a few weeks to get a new doctor assigned by the insurance company. C1 has been doing good in the last couple of weeks according to S2 and administrator. C1 taking the same medications and doing well just like C1 has always been doing. As soon as the administrator can get a new psychiatrist, she will be making an appointment for C1 to be assessed by the new psychiatrist. Interviews with C1 – C3, could not communicate with LPA Soto, could only speak few words, body sign, or were non-verbal. Interview with C4 stated that C1 always screams, but C4 does not know why. Interviews conducted and records reviewed do not concur with the above allegation.

Although the allegation may have happened or is 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 Thana Theng, Administrator, and a hard copy was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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