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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603128
Report Date: 02/09/2024
Date Signed: 02/09/2024 11:06:16 AM

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
08/02/2022 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20220802132138
FACILITY NAME:AZUSA HOMEFACILITY NUMBER:
198603128
ADMINISTRATOR:HOLLAND, TRAVISFACILITY TYPE:
735
ADDRESS:722 W 6TH STTELEPHONE:
(626) 633-1610
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:3CENSUS: 3DATE:
02/09/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Jose AldereteTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Untrained staff giving residents medication.
Staff speak inappropriately to resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent visit in order to deliver findings for the above-mentioned allegations. LPA met with Jose Anderete and explained the reason for the visit. The initial complaint was conducted on 08/11/2022.

The investigation consisted of the following: During the initial complaint visit, LPA Margaryan obtained a copies of the staff roster, clients roster, reviewed C1 file and obtained copies relevant documents. Interviews conducted with Assistant Administrator, Staff #1 (S1), Staff #2 (S2) , Staff #3 (S3), Client #1 (C1), Client #2 (C2) and Client 3 (C3).

Cont. 9099C



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: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20220802132138
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: 02/09/2024
NARRATIVE
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Allegation: Untrained staff giving residents medication. It was alleged that facility staff who administrates medication not trained.
Interviewed Assistant Administrator and staff indicated that proper training has been provided to all staff who assisting clients with medications. Staff training, sign in forms and Training materials were reviewed and it was confirmed that staff assisting with medications have been trained properly.
Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff speak inappropriately to resident in care. it was alleged that Staff #4 and Staff #5 speak inappropriately to C1, saying mean things to him and calling him "Cachino" (disgusting).
Assistant administrator and interviewed staff denied the allegation. They never hear that S#4, S#5 or other staff speak inappropriately to C1 or other clients and called names C1 or other clients. S#4 and S#5 stated that they never said mean things to C1 or other clients. They never called "Cachino" (disgusting) or other names to clients C1. Interviewed clients stated that staff is good.

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. A copy of the report was provided to Jose Alderete
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2