198602619-11-5-2024-11-AS-RORN-DAZRHZ-20241114120311

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602619
Report Date: 11/04/2024
Date Signed: 11/05/2024 07:51:36 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
10/25/2024 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20241025112551

FACILITY NAME:	ACOSTA FAMILY HOME III		FACILITY NUMBER:	198602619
ADMINISTRATOR:	ACOSTA, ASHLEY		FACILITY TYPE:	735
ADDRESS:	875 S ARANBE AVE		TELEPHONE:	(310) 554-4824
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY:	6	CENSUS: 3	DATE:	11/04/2024
		UNANNOUNCED	TIME BEGAN:	10:28 AM
MET WITH:	Jonathan Stump		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not ensure that the client was picked up from the hospital

INVESTIGATION FINDINGS:

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The department conducted an unannounced complaint visit on Monday, November 04, 2024, upon arrival at the facility. The department called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. The department met with staff Jonathan Stump and spoke to Licensee/Administrator Ashley Acosta via telephone. The department explained the purpose of today's visit.
The investigation consisted of the following: Interviews were conducted. The department asked questions pertinent to the nature of the complaint. The department toured the facility's buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No signs of neglect or abuse were observed during today's visit. The department requested and reviewed the client's records and asked for copies of the following documents: Personnel report, Client Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Medication Logs, Consent Forms, Appraisal and Needs Service Plan, Individual Program Plan (IPP), See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

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-20241025112551

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ACOSTA FAMILY HOME III	FACILITY NUMBER: 198602619
	VISIT DATE: 11/04/2024

NARRATIVE

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Continued LIC9099-C page 2
In-service training, Training on Reporting Dependent Adult and Elder Abuse, and hospital admission and discharge records.
Allegation: Staff did not ensure that the client was picked up from the hospital.
The department interviewed Staff 1-2 (S1-S2), who reported that the client moved into the facility on 10/22/24. The client signed out that same day at 2:01 P.M. and checked into the hospital. S1-S2 explained that clients have personal rights and can sign themselves in and out. On 10/23/24, S1 went to Los Angeles General Medical Center to pick up the client after discharge. S1-S2 stated that on 10/24/24, the client signed out at 8:40 A.M., returned to the hospital, and was later picked up by staff. On 10/25/24, the client signed out at 3:50 P.M. and checked back into the hospital; S1-S2 stated staff picked up the client again.
S2 described the client as high-functioning and noted that the client is on a 21-day respite placement, and intended to stay at the facility for a limited time. S1-S2 reported that the client frequently calls 911 and checks in and out of the hospital. When the hospital calls to discharge the client, staff immediately go to pick the client up. S1-S2 noted that the client experiences severe seizures, and once released by a doctor to return to the facility, staff retrieve the client. S1-S2 also stated that the client has a cellphone and always informs staff of their location and whereabouts. S1-S2 denied the allegation. During the interview, Client 1 (C1) called staff via telephone, allowing the department to interview C1, who stated that staff always picked the client up from the hospital. C1 denied the allegation. The department attempted to interview Client 2 (C2), who is non-verbal and could only respond with limited words, such as ‘yes’ or ‘no,' and was unable to answer any of the questions. Client 3 (C3) was at the day program and unavailable for an interview.
The investigation revealed the following:
The department interviewed staff members 1-2 (S1-S2), as well as client 1 (C1) who confirmed that staff picked up the client from the hospital each time the client was discharged. S1-S2 and C1 stated that the client had not been abused by the facility staff. S1-S2 stated the client has a conservator. The client returned to the hospital on 10/24/2024 after signing out from the facility. The client was not at the hospital the entire time after staff picked the client up on 10/23/24. S1-S2 stated that the staff does return the hospital's calls. S1-S2 stated the facility is following Title 22 Regulations. S1-S2 and C1 denied the allegation.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated. There were no deficiencies cited. An exit interview conducted

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

LIC9099 (FAS) - (06/04)

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