198603161-6-22-2021-28-AS-MVAO-C5BQL3-20210727121513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603161
Report Date: 06/22/2021
Date Signed: 06/22/2021 04:01:09 PM

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
01/05/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210105160055

FACILITY NAME:	CALIFORNIA MISSION INN		FACILITY NUMBER:	198603161
ADMINISTRATOR:	LOPEZ, GINA		FACILITY TYPE:	740
ADDRESS:	8417 MISSION DR		TELEPHONE:	(626) 287-0438
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	85	CENSUS: 44	DATE:	06/22/2021
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Haigaz Kazazian, Business Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not adequately supervise resident resulting in a fall.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Noemi Galarza conducted a subsequent complaint investigation visit to deliver findings.The purpose of the visit was explained to Business Director Haigaz Kazazian.

The investigation consisted of the following: On 1/13/2021 due to the COVID-19 pandemic a telephonic visit was conducted. Staff (S1) was interviewed. The Wellness Director/Coordinators and memory care caregivers were not available for interviews. A virtual physical plant tour of Memory Care Unit was conducted at 1:05 PM via FaceTime. No memory care residents were interviewed. On 5/14/2021 a physical plant inspection of the Memory Care unit, assisted living floors, medication room, and common areas was conducted. Staff (S2- S4) were interviewed. The following documents were obtained: Identification and Emergency Information/Face Sheet, Physician Report, Resident Appraisal, Appraisal/Needs and Services Plan, staff contact information, LIC 500, resident roster, and memory care protocols/training log. NOTE: An incident report was not obtained nor submitted via fax to Community Care Licensing.

See LIC 9099C for report continuation.

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: 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-20210105160055

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: CALIFORNIA MISSION INN	FACILITY NUMBER: 198603161
	VISIT DATE: 06/22/2021

NARRATIVE

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Allegation: "Staff did not adequately supervise resident resulting in a fall." Based on interviews conducted the findings indicate that resident (R1) sustained a fall on December 26, 2020. The resident was sitting in a sofa in the Memory Care Unit TV room and fell asleep. Staff (S3) was present during the incident and stated that R1 rolled over while sleeping and fell. The resident hit its forehead and got a bump. It resulted in a bruise to the eyelid area. After the incident staff immediately put an ice pack on the resident and notified the med-tech on duty. A body check was perform and the resident was not sent out to a hospital for an evaluation. The resident did not have history of falls. Staff interviewed stated the incident was not related to lack of staff supervision. According to staff, the staff-to-resident ratio in the Memory Care Unit is 1 to 7. At the time of the incident there was one (1) staff and six (6) residents in the TV room. There is insufficient evidence to prove the alleged allegation.

Based upon records review, interviews conducted, and observations made the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Business Director Haigaz Kazazian. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR 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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