198603111-6-22-2021-28-AS-MVAO-CDMPEM-20220419111520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603111
Report Date: 06/22/2021
Date Signed: 06/22/2021 02:41:23 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
06/14/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210614122847

FACILITY NAME:	A & A CARE HOME		FACILITY NUMBER:	198603111
ADMINISTRATOR:	CABALLES, CRISTINA		FACILITY TYPE:	735
ADDRESS:	21207 WILDER AVE		TELEPHONE:	(562) 233-3125
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90715
CAPACITY:	4	CENSUS: 2	DATE:	06/22/2021
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Administrator Cristina Caballes and Licensee Angelo Caballes		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident was injured by another resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos initiated a complaint investigation for the allegation listed above. LPA met with Administrator Cristina Caballes and purpose of the visit was discussed.

During today's investigation, LPA interviewed Staff #1-#4 (S1-S4), Clients #1-#2 (C1-C2), toured the facility and reviewed client files and incident reports. Spoke with client Placement Agency.

In regards to the allegation "Resident was injured by another resident while in care." it was alleged that C1 was injured by C2 while in care and was not given medical treatment. (4) of (4) staff interviewed denied the allegation. (2) of (2) clients interviewed could not corrborate the allegation. Interviews with staff state that on 6/10/21, C1 and C2 were watching television together when C2 walked away to take a phone call and C1 changed the channel. When C2 returned to the room C2 became upset and had a behavioral outburst and tossed the television controller to the floor.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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-20210614122847

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: A & A CARE HOME	FACILITY NUMBER: 198603111
	VISIT DATE: 06/22/2021

NARRATIVE

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S2 was present to calm down C2. According to S2, they did not witness C2 hit C1. Shortly after, S1 arrived to the facility and noticed a discoloration on C1's face. Staff provided first aid care and called C1's family to notify of the discoloration. Staff was unaware of how the injury was caused, as C1 is non verbal and could not communicate and C2 denied knowing what happened. Staff attempted to take C1 to an urgent care as advised by C1's conservator but they were closed. Staff called the 24/7 nurse hotline and were recommended to just ice the area and schedule a visit with the clients doctor. On 6/13 a behaviorist for the facility had a meeting with C2 who then admitted to hitting C1 with her tablet. Once the facility became aware, they notified C1 and C2's placement agency as well as licensing. C1 was taken to their physician on 6/14 and it was advised to just keep a warm pack around the injury area and no need to go to the hospital. LPA contacted the placement agency which stated they were aware of the incident and do not believe the staff or facility is at fault. Review of client files do not show that clients require a 1 on 1 staff supervision. Facility staff provided first aid and followed up on the injury as well. Based on statements and interviews conducted with clients and staff as well as LPAs documents reviewed, there was not enough supportive evidence to corroborate the allegation. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all the allegations are UNSUBSTANTIATED.

An exit interview was conducted with administrator Cristina Caballes and Licensee Angelo Caballes and a hard copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC9099 (FAS) - (06/04)

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