198603020-8-1-2023-28-AS-RORN-CVNM23-20230914091253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603020
Report Date: 08/01/2023
Date Signed: 08/01/2023 04:40:46 PM

Unsubstantiated

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
07/28/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230728163709

FACILITY NAME:	FMJVITACARE1 CORP		FACILITY NUMBER:	198603020
ADMINISTRATOR:	ALICE REYES		FACILITY TYPE:	735
ADDRESS:	2718 BLAKEMAN AVE		TELEPHONE:	(909) 641-7109
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY:	4	CENSUS: 4	DATE:	08/01/2023
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Liezlann Fernandez		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff sleep while on shift
Staff did not provide adequate assistance to client in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wong conducted an intial 10 days visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint.
LPA met with the House Manager Liezlann Fernandez and explained the reason of the visit and assisted LPA with the visit.

The investigation consisted of the following: LPA interviewed house manager, three staff (S1-S3) and four clients (C1-C4) in the facility and administrator via telephone. LPA also reviewed all four clients medication and Medication Administration Records (MARs). LPA also obtained copy of documents for C1.

(See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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-20230728163709

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: FMJVITACARE1 CORP	FACILITY NUMBER: 198603020
	VISIT DATE: 08/01/2023

NARRATIVE

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The investigation revealed of the following: Allegation#1 "Staff sleep while on shift" LPA interviewed clients and all denied the allegation and reported they never saw staff sleeping while working. While LPA interviewed C1 and C1 recanted and stated staff was not working at that time and staff show up early at work and that's why staff eyes were closed. LPA interviewed staff and staff denied the allegation and reported they never saw any staff was sleeping while on shift. Staff and Administrator reported they were allowed to have 10 and 30 minutes break during their 8 hours shift work.

Allegation#2 "Staff did not provide adequate assistance to client in care " LPA interviewed clients and denied the allegation and reported staff never forgot to give medication to clients. Staff always give them medication on time and never missed any medication. LPA interviewed staff and denied the allegation and reported they always give the medication in front of the client and ensure they do not spit the medication and they would check the surrounding area and make sure the medication does not drop on the floor or the sink. In addition, another staff would double check the bubble pack medication and MARs and ensure client does take their medication. Staff also reported they never saw C1 choked or spit the medication in the drinking cup. LPA also inspected all four clients' medication and they are all seemed updated and accurate.

Based on record review and interviews, investigation revealed: 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 UNSUBSTANTIATED.

Exit Interview conducted. A copy of the report and the appeal right was provided to House Manger Liezlann Fernandez

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC9099 (FAS) - (06/04)

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