198603012-10-7-2022-28-AS-RORN-CKYRV9-20221108122103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603012
Report Date: 10/07/2022
Date Signed: 10/07/2022 01:19:30 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
09/30/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220930115743

FACILITY NAME:	INSPIRED ELDERLY CARE LIVING		FACILITY NUMBER:	198603012
ADMINISTRATOR:	GALLEGOS, LAURIE		FACILITY TYPE:	740
ADDRESS:	1438 E PORTNER STREET		TELEPHONE:	(909) 240-1321
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	6	CENSUS: 6	DATE:	10/07/2022
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Laurie Gallegos, Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff are not following Covid-19 masking protocols.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation on Staff not following Covid-19 masking protocols. LPA arrived unannounced and was allowed entry by Staff. LPA met with Laurie Gallegos and explained the purpose of the visit.

LPA obtained a copy of the staff and resident roster. Interviews were conducted with the Administrator, 2 Staff, and 3 Residents. The other 3 residents could not communicate with LPA.

On this allegation, staff are not following COVID-19 masking protocols. During the visit, LPA arrived at 11:50 a.m. and did not observe Staff #1 wearing a mask when staff opened the door. Staff #1 immediately put on a mask after LPA greeted herself and proceeded to take LPA’s temperature. LPA observed another staff with a N95 mask but was not wearing it properly to cover the nose or mouth.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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 28-AS-20220930115743

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: INSPIRED ELDERLY CARE LIVING	FACILITY NUMBER: 198603012
	VISIT DATE: 10/07/2022

NARRATIVE

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The Administrator was outdoor with some residents along with a family member who were not wearing face coverings. Per the Administrator, she stated that the masking is not required for outdoor visitations. She indicated that staff do not wear them consistently indoors due to residents not being able to hear them speak and/or wanting to see their full face. Staff interviewed stated they wear a mask every time they assist a resident. LPA was able to interview 3 residents today. One indicated that the staff have not been wearing the face masks often, while another was not sure. One stated that the staff wear them all the time when assisting them.

Per CA Dept of Public Health guidance, In the following healthcare and long-term care indoor settings, masks are required for all individuals regardless of vaccination status.

Based on LPA observations, 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 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220930115743

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: INSPIRED ELDERLY CARE LIVING	FACILITY NUMBER: 198603012
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/14/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as required by:	1 2 3 4 5 6 7	The Administrator shall conduct a training with staff to review masking protocols. The log shall be submitted to LPA by POC 10/14/22.
	8 9 10 11 12 13 14	Based on observation, staff were not wearing a mask or properly wearing a mask which is a potential health and safety, personal rights 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.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

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