198602996-12-5-2024-11-AS-UCOL-DBTTAC-20241210133316

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602996
Report Date: 10/10/2024
Date Signed: 12/05/2024 02:31:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2024 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20241001101208

FACILITY NAME:	SAR ADULT HOME CARE		FACILITY NUMBER:	198602996
ADMINISTRATOR:	SAR, VASHNA		FACILITY TYPE:	735
ADDRESS:	926 E 163RD ST		TELEPHONE:	(562) 301-6726
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY:	4	CENSUS: 4	DATE:	10/10/2024
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	ADMINISTRATOR VASHNA SAR		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff are stealing from resident.
Staff are isolating resident.
Staff are sharing resident's personal information.

INVESTIGATION FINDINGS:

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This report is an amendment of the complaint investigation dates 10/10/2024. The purpose of this amendment is to provide additional information to the complaint investigation. The findings remain Unsubstantiated.
Community Care Licensing Division (CCLD) on conducted an unannounced visit to SAR Adult Home Care Facility on 10/10/2024 and was greeted by Administrator Vash Sar (S1). CCLD staff explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
The investigation consisted of the following: CCLD staff interviewed Administrator (S1), staff (S1-S2), residents (R1-R4). CCLD staff requested and reviewed copies of the following: Physician Report (dated 01/04/2024), Needs and Services Plan (dated 01/12/2024), incident report (dated 05/31/2024 to 10/09/2024), admission agreement (dated 01/25/2024), surety bond (date 05/15/2024), P&I accounts (2023 and 2024) for R1-R4. The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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-20241001101208

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SAR ADULT HOME CARE	FACILITY NUMBER: 198602996
	VISIT DATE: 10/10/2024

NARRATIVE

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Regarding Allegation #1: Staff are stealing from residents. It is being alleged that staff stole residents’ personal and incidental (P&I) money. CCLD staff toured the facility and noted administrator documenting the account for R1 money account. Record review indicate that there are 4 P&I ledgers. Records indicate that residents take out their money in full every month and there is a zero balance. The ledger is kept current, and no errors are found. LPA Calderon noted a surety bond for $4000.00 was posted. Reviewed 11 incident reports from 05/23/2024 to 10/09/2024. Incident report for 09/17/2024 indicates that 1 out of 4 residents claims that the staff stole $4000.00 of which $531.00 is owed. 2 out of 2 staff indicate that only the administrator deals with resident money and that accurate records are kept. R1 indicates that S1 did not pay what was due to R1 on time but got the money eventually. 3 out of 4 residents indicate that S1 gives them their money and that every month there is a zero balance in their account.

Regarding Allegation #2: Staff are isolating residents. It is being alleged that the staff are not allowing residents to socialize. CCLD staff noted residents leaving for day program and leaving the facility interact with the outside world. Records indicate that R1 has health issues. 2 out of 2 staff indicate that residents go to day program every day and have family and guest visits. 2 out of 2 staff indicate that resident leave the facility and are never isolated from other people. 3 out of 4 residents indicate that the staff has never isolated them. 3 out of 4 residents indicate that they go to day program and interact with family and friends.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241001101208

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SAR ADULT HOME CARE	FACILITY NUMBER: 198602996
	VISIT DATE: 10/10/2024

NARRATIVE

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Regarding Allegation #3: Staff are sharing residents’ personal information. It is being alleged that the staff are sharing residents’ personal information.2 out of 2 staff indicate that they never share residents’ information with outside vendors except residents’ doctors. 1 out of 4 residents indicates that they made a mistake, that it was the day program and not the facility shared their personal information.4 out of 4 residents indicate that staff do not share their information with anyone except their doctors.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “staff are stealing from resident”, “staff are isolating resident”, “staff are sharing residents’ personal information” is found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Vash Sar S1.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

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