<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602571
Report Date: 02/03/2023
Date Signed: 02/03/2023 03:46:50 PM

Substantiated


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
01/27/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230127095834
FACILITY NAME:A AND M ARMOUR HOME CAREFACILITY NUMBER:
198602571
ADMINISTRATOR:SYLVIA OWENSFACILITY TYPE:
735
ADDRESS:2145 ARMOUR STREETTELEPHONE:
(909) 618-7065
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY:4CENSUS: 4DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Sylvia Owens, Mona De La Rosa and Lady Roxanne ArcibalTIME COMPLETED:
03:51 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client in care sustained unexplained injuries
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to facility for the purpose of investigating the allegation above. LPA met with Administrator Sylvia Owens and Licensee Mona De La Rosa and explained the reason for the visit. Facility coordinator Lady Roxanne Arcibal arrived late also assisted with visit. The purpose of the visit is to investigate the above allegation.

LPA conducted interview with Administrator
LPA obtained and reviewed staff and resident rosters.
Interviews were conducted with Staff S1 – S8
Interviews were conducted with W1-W6
Interviews were conducted with Client C1 - C4. All clients were limited in their response to questioning.
LPA reviewed C4's file, Emergency ID page and Special Incident Report.

Continued on 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20230127095834
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: A AND M ARMOUR HOME CARE
FACILITY NUMBER: 198602571
VISIT DATE: 02/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Client in care sustained unexplained injuries. It is alleged that client sustained unexplained injuries to face on 01/25/2023

Based on interviews conducted and information gathered, staff stated that C4 left early morning to on 01/25/2023 to day program and did not have any visible injuries to face. 9 of 9 staff interviewed stated that the injuries to C4 did not occur at the facility. LPA interviewed 2 staff at day program, and both stated that C4 arrived at the day program with the injuries to C4 face and alerted the facility. LPA interviewed transportation assistants W4 and W5 and W4 and W5 stated that W4 and W5 did not recall seeing C4 with injuries to his face during transportation from facility to day program LPA was not able to determine how client in care sustained injuries.

Deficiencies cited, please see 9099D for details.

Based on interviews conducted with facility staff, day program staff, other witnesses and review of records, the preponderance of evidence standard has been met, therefore the above stated allegation is found to be SUBSTANTIATED.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 28-AS-20230127095834
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: A AND M ARMOUR HOME CARE
FACILITY NUMBER: 198602571
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2023
Section Cited
CCR
80072(a)(2)
1
2
3
4
5
6
7
80072 Personal Right(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
1
2
3
4
5
6
7
The administrator will ensure each client to be accorded safe, healthful and comfortable to meet their needs. The administrator will write a letter stated that they would re-train the staff for personal rights and send to LPA by POC due date.
8
9
10
11
12
13
14
The requirement is not met as evidenced by interviews with parent of the client, day program staff and staff at facility observed client with unexplained injuries to face and cause is unknown which poses an immediate Health and Safety risk to residents in care..
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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3