198603104-1-9-2024-28-AS-LHIS-CZDN8V-20240111091459

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603104
Report Date: 01/09/2024
Date Signed: 01/09/2024 12:46:12 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
01/03/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240103124655

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: 4	DATE:	01/09/2024
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Eleanor Lopez, DSP		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Facility staff did not seek timely medical attention for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegations. The purpose of the visit was explained to staff Texon Rosario. Administrator was explained the purpose of the visit and interviewed telephonically.

The investigation consisted of the following: A physical plant tour of the interior and exterior of the facility was completed, Staff (S1-S4) and resident (R2) were interviewed. Residents (R1, R3, & R4) are non-verbal and were not interviewed. Family (F1) and Behavioral Management Assistant- Abeita & Associates were interviewed. Resident (R1's) file documents were obtained [Identification and Emergency Information, Physician Report, Individual Program Plan (IPP), MARs, hospital report/discharge documents, incident report (12/30/23), resident names list and LIC 500 Personnel Report.

***Report continues next page.****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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 28-AS-20240103124655

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: 01/09/2024

NARRATIVE

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Allegation: Facility staff did not seek timely medical attention for resident. It is alleged that resident (R1) had been showing signs of sickness i.e., coughing and slight fever since Thursday, December 28, 2023, but staff waited to send out R1 to the hospital until Sunday, December 31, 2023 upon R1's family request to facility staff that resident (R1) began showing signs of sickness (coughing) on Saturday, December 30, 2023. A total of four (4) staff were interviewed of which all denied the allegation. Staff stated that they follow physician orders and always seek medical attention for residents if it is determined to be a medical emergency. Caregiver staff reported that R1's family and Assistant Administrator were notified that R1 had coughing symptoms. Administrator stated that the decision to call 911 on Dec. 31, 2023, was made because R1 is medically fragile with heart failure. According to staff, Assistant Administrator contacts resident's physician's when needed and obtains medical care instructions. According to staff interviews, the reason R1 was hospitalized was due to heart failure exacerbation, which caused difficulty breathing and not pneumonia as alleged in this complaint. The resident was admitted to the hospital on Dec. 31, 2023 and discharged on Jan. 5, 2024. R1 remained at the hospital extra days due to unstable blood pressure.

LPA interviewed family (F1) and stated that they were notified of coughing on December 30, 2023. They do not feel resident (R1's) health was neglected. R1's Behavioral Management Assistant was at the facility today, and was also interviewed. It was reported that R1 has been medically stable, has one to one 24 hour care and there have been no medical care concerns. Per record review, R1 is medically fragile with multiple heath diagnosis [congestive heart failure, heart edema, history of pneumonia and upper respiratory infections]. Medication administration records (MARs) indicate staff administered PRN cough medication Promethazine-DM 6.25-15 mg/5ml on December 29, 2023 & December 30, 2023. LPA reviewed hospital report/discharge documents, which indicated the resident was treated with heart failure exacerbation. The facility only has one (1) verbal resident. Resident (R2) stated that R1 "looked alright" before being transported to the hospital, and staff are not negligent with medical care appointments. There is insufficient evidence to corroborate the allegation.

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.

An exit interview was conducted and a copy of this report was discussed and provided to facility staff Eleanor Lopez.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC9099 (FAS) - (06/04)

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