198602627-1-18-2023-11-AS-MVAO-CNDRFW-20230124115950

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602627
Report Date: 01/18/2023
Date Signed: 01/18/2023 06:48:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
01/12/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230112153507

FACILITY NAME:	CALIFORNIA MENTOR - 230TH STREET HOME		FACILITY NUMBER:	198602627
ADMINISTRATOR:	ROSAS, CLAUDIO		FACILITY TYPE:	735
ADDRESS:	434 W 230TH STREET		TELEPHONE:	(909) 483-2505
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	3	CENSUS: 3	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Kristina Moralez & Shannon Hamling		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff retaining a resident that requires a higher level of care.
Staff not adequately trained to meet the needs of resident in care.

INVESTIGATION FINDINGS:

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On 01/18/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility. Upon arrival, LPA conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. As part of today's visit, LPA met with Kristina Moralez DSP and Claudio Rosas Program Director over the phone and explained that this visit was to investigate the allegations.

The investigation consisted of the following: Interviews conducted with staff. Inquiries related to the complaint were made by the LPA. A tour of the facility and grounds was conducted and to observe and identify any signs of neglect, abuse, or other threats to immediate health and safety. LPA requested and reviewed client #1 (C1's) records and requested copies of supporting documents.

Evaluation Report continues.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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 11-AS-20230112153507

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CALIFORNIA MENTOR - 230TH STREET HOME	FACILITY NUMBER: 198602627
	VISIT DATE: 01/18/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff retaining a resident that requires a higher level of care.
Staff not adequately trained to meet the needs of resident in care.

The reporting party requested for The Department to investigate the allegations mentioned above. The reporting alleged client #1 (C1) requires a higher level of care and that staff does not adequately train to meet the needs of (C1). The reporting reported that (C1) requires staff assistance on Gastrostomy Tube (G-Tube) and believes that (G-Tube) requires higher level care. (C1) is a Harbor Regional Center consumer and was admitted to this facility on 06/06/22. (C1) is diagnosed with Cerebral Palsy and intellectual disability. (C1) health needs require help with a seizure disorder, vagus nerve stimulation, and activities of daily living (ADL). (C1) is also on a special diet that requires (G-Tube). Based on a review of client service records client #1-#3 (C1-C3), the Department found that no higher level of care was necessary for any of the clients. The service records revealed that (C1) is dependent on a Gastrostomy Tube for feeding and mediation administration. Nevertheless, (G-Tube) does not fall under the category of a restricted health condition under Title 22 , Division 6 Chapter 1. Interviews with staff #1-#6 (S1-S6) verified (C1) is assisted in feeding and medication administration through (G-Tube) by trained professional staff. Interviews with clients #1-#2 (C1-C2) were no feasible as both residents were in the hospital. (C3) who was present at the facility was unable to hold a conversation as a result of her disability.

Staff at this facility are not adequately trained to meet the needs of residents in care, including client #1(C1), Based on interviews with staff #1-#6 (S1-S6), it revealed that all staff received comprehensive Gastrostomy Tube training from a licensed registered nurse staff #6 (S6). Before (C1) was admitted to the facility, (S1-S6) were verified, and a combination of classroom and hands-on training was completed. There is 24/7 assistance from a licensed vocational nurse (LVN) and registered nurse (RN) for additional education and monitoring is available. In accordance with (S1-S6) training and monitoring of (G-Tube), procedures is continuous. A review of the facility's training logs verified this information. A few courses endorsed by Harbor Regional Center that staff must complete included medication care, fall prevention, documentation, first aid/CPR, reporting requirements and crisis prevention Direct Support I & II are a few courses required by the facility to qualify for employment. Based on information gathered, there's no evidence to corroborate the allegations mentioned above.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230112153507

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CALIFORNIA MENTOR - 230TH STREET HOME	FACILITY NUMBER: 198602627
	VISIT DATE: 01/18/2023

NARRATIVE

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Based on the information provided, the Department finds the facility is not in violation of Title 22 Regulations and no evidence supports the allegations mentioned above.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegations are Unsubstantiated.

No deficiencies were cited during this visit.

An exit interview was conducted with Shannon Hamling, and a copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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