198603128-10-24-2023-28-AS-RORN-CX5L8A-20231031083133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603128
Report Date: 08/11/2022
Date Signed: 10/24/2023 02:19:05 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
08/01/2022 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20220801170658

FACILITY NAME:	AZUSA HOME		FACILITY NUMBER:	198603128
ADMINISTRATOR:	HOLLAND, TRAVIS		FACILITY TYPE:	735
ADDRESS:	722 W 6TH ST		TELEPHONE:	(626) 633-1610
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY:	3	CENSUS: 3	DATE:	08/11/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Mirna Alderete		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff overmedicate client
Licensee is not providing medical information to client’s authorized representative
Facility does not have an adequate supply of food
Facility is not serving the necessary quantity of food to meet the needs of clients

INVESTIGATION FINDINGS:

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This is an amended report which supersedes the original report dated 8/11/22. The purpose of this report is to remove confidential information and make corrections to the report. The amendments to the report do not affect or change the findings on this complaint.
Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Yolanda Ramirez and explained the reason for the visit. Administrator and Assistant Administrator were notified about visit over the phone. Assistant Administrator arrived to the facility at 1:30 pm
The investigation consisted of the following: LPA Margaryan toured the kitchen, obtained a copies of the staff roster, clients roster, reviewed C1 file and obtained copies of Admission Agreement, Face Sheet, Physician's Report, Physician Order, Medication Log, Weight Record. LPA also obtained copies of Food Menu for the Month of August and Grocery shopping receipts for July and August. Interviews conducted with Assistant Administrator, Staff #1 (S1), Staff #2 (S2) , Staff #3 (S3), Client #1 (C1), Client #2 (C2) and Client #3 (C3).
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Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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-20220801170658

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: AZUSA HOME	FACILITY NUMBER: 198603128
	VISIT DATE: 08/11/2022

NARRATIVE

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The investigation revealed the following:
Allegation - Staff overmedicate client. It was alleged that C1 is being given Ativian to calm C1 down to the point that he is groggy, and sleeping a lot. Because of C1’s disability C1 screams for long periods of time. To investigate this allegation, LPA interviewed three (3) staff, and the Assistant Administrator. It was alleged that staff are overmedicating C1 with Ativian to calm C1 down to the point that he is groggy and sleeping a lot. Based on document review, LPA observed that C1 does have a prescription for Ativian to be taken as needed. Ativian is the generic for Lorazepam and prescribed by the doctor. LPA reviewed medication log and did not observe any discrepancies regarding the Ativian / Lorazepam medication. All interviewed staff and Assistant Administrator denied the allegation. They stated no one overmedicating C1 or other clients to calm them down to the point to sleeping a lot. Staff understand that clients can have different behaviors because of their disabilities and they trained to handle the situation when clients have a behavior issues. Based on the interviews and record reviews LPA observed that facility is following Title 22 Regulations regarding PRN medications. Medication is given according to the physician's directions.

Allegation - Licensee is not providing medical information to client’s authorized representative
It was alleged that RP requested C1's doctor's name, list of current prescriptions and insurance information
but Licensee not provided any information.
Interviewed Assistant Administrator denied the allegation. Assistant Administrator. stated none of the family members requested medical information for C1. He stated that information will be provided to family / conservator immediately by their request. Assistant . Administrator stated that sometimes family members taking clients to the doctors appointments and Facility staff always provide them information that they needed (doctor's name, address, insurance information). Interviewed staff stated they didn't hear any complains from family members about not getting requested documents or information.

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NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220801170658

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: AZUSA HOME	FACILITY NUMBER: 198603128
	VISIT DATE: 08/11/2022

NARRATIVE

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Allegations - Facility does not have an adequate supply of food. Facility is not serving the necessary quantity of food to meet the needs of clients.
It was alleged that C1 has lost over 10 lbs. because food portions are very limited. The refrigerator is practically empty and they have very little canned food.
LPA toured the kitchen and observed various food items in the refrigerator such as different types of meats, ground beef, chicken, cheese, Thick Bologna, waffles, and eggs. LPA also observed a variety of vegetables such as bell peppers, tomatoes, lettuce, onions, and other frozen veggies. Fruits observed included bananas, oranges, apples . LPA observed canned foods as well gallons of drinking water. LPA observed nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days at the facility during the visit. LPA interviews with S1 - S3 and Assistant Administrator revealed that staff felt that there is a sufficient amount of food along including nutritious variety and drinking water available for the clients at the facility at all times. They stated that the food portions that clients are served are always properly balanced. Clients always can ask for more food. LPA observed the meal that was served to the residents at the time of visit. The portions of the meals were appropriate. Interviewed clients confirmed that they like the food and on LPA's question that they need more they said no. Pictures of food supply and served meals were taken by LPA during today's visit. LPA Margaryan also requested and reviewed C1's weight record. LPA observed that C1's weight fluctuates between 119 to 117 pounds. Facility keeps the records of weight for clients. Assistant Administrator stated they will be worry when client will loose 5 or more pounds and it will be reported to Primary Physician.

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.

An exit interview was conducted and the copy of this report provided to Mirna Alderete

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

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