198603104-9-14-2022-28-AS-MVAO-CJHSPR-20220922140334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603104
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:27:14 PM

Unsubstantiated

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
09/13/2022 and conducted by Evaluator Noemi Galarza

COMPLAINT CONTROL NUMBER: 28-AS-20220913140358

FACILITY NAME:	TOMINES ADULT RESIDENTIAL FACILITY I		FACILITY NUMBER:	198603104
ADMINISTRATOR:	TOMINES, JONATHAN		FACILITY TYPE:	735
ADDRESS:	6234 N BURTON AVE		TELEPHONE:	(626) 848-8836
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	4	CENSUS: 2	DATE:	09/14/2022
		UNANNOUNCED	TIME BEGAN:	12:53 PM
MET WITH:	Jasmin Tomines, Assistant Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Neglect/lack of supervision led to hospitalization of client.
Facility staff failed to notify authorized representative of client's condition prior to hospitalization.
Client sustained unexplained bruising.
Medication was not administered according to physician's directions.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegations.The purpose of the visit was discussed with Assistant Administrator Jasmin Tomines.

The investigation consisted of: A physical plant tour of the home and interviews with staff (S1-S3), and family member (F1). Client (C1 & C2) are non-verbal and were not interviewed. Documents pertaining to C1 were obtained: Face Sheet/Emergency Information, Physician's Reports, Positive Support Plans/Behavior Annual Report, Individual Program Plan (IPP), Letters of Conservatorship, Medication Administration Records (Jan. 2022 & Sep. 2022), incident report (1/19/22 & 7/17/22) LIC 500 Personnel Report, and client roster.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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-20220913140358

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: TOMINES ADULT RESIDENTIAL FACILITY I	FACILITY NUMBER: 198603104
	VISIT DATE: 09/14/2022

NARRATIVE

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Allegation: "Neglect/lack of supervision led to hospitalization of client." It is alleged that client (C1) was hospitalized on January 19, 2022 as a result of neglect of health that resulted in a pneumonia diagnosis. Client (C1) has congestive heart failure, which makes the client prone to accumulation of fluid in the lungs. On January 17, 2022 staff called C1's Primary Care Physician (PCP) to report a slight cough. The facility was instructed to administer PRN cough medicine. On January 18, 2022, staff called the PCP because C1's cough persisted. A new cough medicine was prescribed by MD, and staff were instructed to monitor client's blood pressure and oxygen levels. On January 19, 2022, Assistant Administrator called C1's MD because the client did not look well. Per physician's order, staff was instructed to call 911. C1's sister was present and made the 911 call that resulted in C1's hospitalization. In regards to the most recent hospitalization (7/17/2022), client (C1) was staying at it's family's home and began to get ill. Family notified C1's primary physician and 911 was called. C1 tested positive for COVID-19 virus at the hospital. The client was treated for mild pneumonia and discharged 2 days later. Based on record review and interviews conducted the findings indicate staff contacted C1's MD in a timely manner and client received medical care per physician orders.

Allegation: "Facility staff failed to notify authorized representative of client's condition prior to hospitalization." Based on interviews conducted and record review the findings indicate that client (C1's) authorized representatives were notified of C1's cough and decline in health on January 17, 2022, the day the client developed a cough. All staff stated that C1's authorized representatives are always immediately contacted because they are very involved in the client's care and want to be immediately notified of any changes in condition. Family member (F1) stated that on January 17, 2022 staff called to notify about client's cough, physician instructions; and this information was communicated with other family members. Therefore, this allegation is not supported.

See LIC 9099C for report continuation.

SUPERVISOR'S NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220913140358

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: TOMINES ADULT RESIDENTIAL FACILITY I	FACILITY NUMBER: 198603104
	VISIT DATE: 09/14/2022

NARRATIVE

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Allegation: "Client sustained unexplained bruising." It is alleged that client (C1) has had unexplained scratches/bruising on the head and both legs as a result of lack of supervision during the past 2 years, and that the facility has said it may have happened at the day program. All staff denied physical abuse or lack of supervision. Administration staff stated that client has self-injurious behaviors in which client (C1) scratches it's head, shins, bites it's hands, and hits furniture. As a result, in May 2022 the Eastern Los Angeles Regional Center (ELARC) approved a one (1) to one (1) caregiver for the client in order to minimize the self-injurious behaviors. The client continues to have these behaviors, but they have significantly decreased. Staff reported the client is very fast, and occasionally scratches it self when staff is next to the client. During today's visit, LPA observed a self-injurious behavior while the client sat next to staff and LPA. The client's Individual Program Plan (IPP) report has self-injurious behaviors documented. No recent scratches, bruising, or wounds were observed today. Therefore, there is insufficient evidence to corroborate the allegation.

Allegation: "Medication was not administered according to physician's directions." It is alleged that staff are administering Benadryl PRN medication to client (C1) without a physician's order. The incident allegedly happened in late 2021. However, the picture proof obtained was not medication Benadryl; it was Quetiapine Fumurate dated 2019. Per review of medication records, Quetiapine Fumurate is a prescribed medication. All staff stated only medications prescribed by physician's are administered. They denied administering Benadryl to client (C1) in recent years. Staff reported that on several occasions client (C1's) family member has brought over the counter medications and asked staff to administer the medications. The family member has been told that only medications ordered by C1's physician's are administered. There is insufficient evidence to support this allegation.

Based upon records review, interviews conducted, and observations made the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was held with Assistant Administrator Jasmin Tomines. A copy of this report was issued.

SUPERVISOR'S NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

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