198602890-5-2-2021-28-AS-MVAO-C2PP3N-20210504105749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602890
Report Date: 05/02/2021
Date Signed: 05/02/2021 04:29:42 PM

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 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
10/28/2019 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20191028121513

FACILITY NAME:	J AND C HOUSE OF LOVE		FACILITY NUMBER:	198602890
ADMINISTRATOR:	WISE, CHANTE		FACILITY TYPE:	740
ADDRESS:	12121 164TH STREET		TELEPHONE:	(562) 229-9957
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 4	DATE:	05/02/2021
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Administrator, Chante Wise		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff failed to correctly administer resident's medications.
Facility staff failed to give resident medication on a timely basis.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz initiated a subsequent complaint visit to conduct further investigation from a visit conducted on 11/07/2019 by LPA Juan Pablo Miramontes, for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with Chante Wise, Administrator.

Investigation consisted of the following: Obtained a copy of the current staff/resident roster.
LPA reviewed the facility record files for Residents #1-#3, which included, Medication Administration Record (MAR). LPA obtained copies of the following documents, which included, but not limited to: Physician's Report, MAR and list of medications. LPA conducted an interview with Administrator Chante Wise. LPA was unable to interview Staff #1, as staff is no longer employed with the facility. LPA interviewed Residents #1-4 and Staff #2. (Continud on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2021

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 4

Control Number 28-AS-20191028121513

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: J AND C HOUSE OF LOVE	FACILITY NUMBER: 198602890
	VISIT DATE: 05/02/2021

NARRATIVE

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Investigation revealed the following: Upon reviewing medication list and the MAR log it was determined that although there was a discrepancy on the handwriting MAR and the physician's written order correlated to each other. Based on documentation reviewed LPA was unable to determine if facility was not administrating medications correctly and on a timely basis, as the MAR did not indicate missed medications. On 11/07/2019, LPA Miramontes did pill count and were accurate.

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.

A telephonic exit interview was conducted with Administrator and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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 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
10/28/2019 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20191028121513

FACILITY NAME:	J AND C HOUSE OF LOVE		FACILITY NUMBER:	198602890
ADMINISTRATOR:	WISE, CHANTE		FACILITY TYPE:	740
ADDRESS:	12121 164TH STREET		TELEPHONE:	(562) 229-9957
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 4	DATE:	05/02/2021
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Administrator, Chante Wise		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff failed to inform and communicate with resident's legal representative.

INVESTIGATION FINDINGS:

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****This an amendment to the complaint investigation report that was delivered on 11/07/2019. This amendment supersedes the original complaint investigation report and to correct the finding selected on LIC 9099, the finding for the allegation remains the same. ****

Licensing Program Analyst (LPA) Linda Almaraz initiated a subsequent complaint visit to conduct further investigation from a visit conducted on 11/07/2019 by LPA Juan Pablo Miramontes, for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with Chante Wise, Administrator.

Investigation consisted of the following: LPA reviewed the facility record files for Residents #1, which included, but not limited to Medication Administration Record (MAR) and medications list. LPA conducted an interview with Administrator Chante Wise. (Continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20191028121513

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: J AND C HOUSE OF LOVE	FACILITY NUMBER: 198602890
	VISIT DATE: 05/02/2021

NARRATIVE

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Investigation revealed the following: During interview LPA inquired if facility staff informed and communicated with resident's legal representative of activities related to the services being rendered to the resident. Administrator Wise stated that the resident's legal representative was not informed that resident's medications were cut by a different pharmacy not utilized by the resident.

Based on LPA’s interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, was cited on LIC 9099D on 11/07/19.

A telephonic exit interview was conducted with Administrator and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4