198603126-11-7-2023-28-AS-DSIS-CXNVKW-20231117153100

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603126
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:35:20 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
11/02/2023 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231102145937

FACILITY NAME:	ANL FACILITY HOME INC		FACILITY NUMBER:	198603126
ADMINISTRATOR:	BULOSAN, LUZVIMINDA A		FACILITY TYPE:	740
ADDRESS:	12073 HIGHDALE ST		TELEPHONE:	(562) 310-4871
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 6	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Luzviminda Bulosan - Administrator		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff are not properly trained

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial complaint visit regarding the allegation listed above. LPA met with Luzviminda Bulosan, administrator of the facility.

The investigation consisted of the following: LPA interviewed Residents #1, 3, and 6 (R1, R3, R6), interviewed Staff #2 - 4 (S2 - S4), and also obtained Staff #1's (S1's) complete training records and reviewed the training records for all staff that work at the facility along with their associations in Guardian. LPA attempted to interview S1, however they were not present in the facility. LPA attempted to interview Residents #2, 4, and 5 (R2, R4, R5), however they were not able to answer questions due to cognitive impairment.

The investigation revealed the following: in regards to the allegation "Staff are not properly trained", it is alleged that S1 along with one of their siblings have been working at the facility after 6 PM, and that they are not been properly trained which have led to resident falls when transferring them.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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-20231102145937

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: ANL FACILITY HOME INC	FACILITY NUMBER: 198603126
	VISIT DATE: 11/07/2023

NARRATIVE

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During interviews with the Residents, none of them corroborated that S1 is not a properly trained staff member, nor that S1's sibling works at the facility. Both R3 and R6 explained that S1 is very helpful and very nice to both of them, and that the sibling of S1 does come to the facility as well but they do not witness the sibling performing caregiving duties and only comes to have conversation with them. During interviews with the staff, none of them corroborated that S1 is not properly trained, nor that the sibling of S1 works at the facility. S3 and S4 explained that S1 is their child and is properly trained and associated in the Guardian system. S3 and S4 explained that the sibling is also their child and occasionally comes to visit the facility on Saturdays for dinner because the sibling enjoys speaking with the residents, however they are currently a student in college and do not perform any caregiving duties. During record reviews of S1's training and the other staff members, LPA observed that all staff completed the required initial 40 hours of training upon hire, including the necessary 6 hours dedicated to Dementia Care along with 4 hours dedicated to Hospice Care, Postural Supports, and Restricted Health Conditions. LPA also observed training conducted for this year, and S4 explained that the facility staff will meet the annual training requirements by the end of the year.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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