198603161-4-15-2021-28-AS-LHIS-C6QS72-20210910133646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603161
Report Date: 04/15/2021
Date Signed: 04/15/2021 04:07:54 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
04/08/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210408115905

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: 31	DATE:	04/15/2021
		UNANNOUNCED	TIME BEGAN:	09:49 AM
MET WITH:	Kathleen Olson, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff will not give resident access to file.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was explained telephonically to Administrator Kathleen Olson and Operations Director Tyler Cheney.

The investigation consisted of interviews with staff (S1-S5), residents (R2-R6), and document review. The following documents were provided until later in the day: R1's Emergency Information/Move In Record, copy of R1's COVID-19 vaccine card, physician report, resident contact information, LIC 500 Personnel Report, and resident roster.

See LIC 9099C for continuation of report.

Substantiated

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: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

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-20210408115905

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: 04/15/2021

NARRATIVE

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Allegation: "Staff will not give resident access to file." Based on interviews conducted and document review the findings indicate there were three (3) on-site COVID-19 vaccine clinics [January 20, 2021, February 10, 2021, and March 3, 2021]; in which residents received the Pfizer vaccine. After resident (R1) was fully vaccinated, the resident requested the original Center for Disease Control COVID-19 Vaccination Card, but was not provided the card. Resident (R1) requested the card from former Wellness Director, and caregiver Coordinator staff but was only provided copies of the vaccination card. Resident (R1) was discharged on March 1, 2021 and was not provided the original COVID-19 vaccination card upon discharge. Staff (S3) stated that resident returned at a later date and was given the original card. However facility did not provide proof that resident received the original vaccine card.

According to staff interviews, there were changes in Administration staff in February 2021. Former Administrator and former Wellness Director staff were in charge of the COVID-19 vaccine cards. Approximately, two (2) weeks ago the resident's COVID-19 vaccination card records were not found. They were located until the following day. Staff interviews revealed the original vaccination cards were not given to residents. They remained in the possession of Administration staff for safe keeping. Residents only received a copy of the vaccination card. Five (5) out of five (5) residents stated that as of today they have not been given the original COVID-19 vaccination card.

According to Title 22, Division 6, Health and Safety Code, Chapter 3.2 Residential Care Facilities for the Elderly, Article 02. Licensing: 1569.153(e) Theft and loss program; standards, property inventories and surrender of personal effects; secured areas. Inventory and surrender of the resident's personal effects and valuables upon discharge to the resident or authorized representative in exchange for a signed receipt.

Based on interviews and information obtained the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Health and Safety Code, Chapter 3.2, Article 02. See LIC 9099D.

A telephonic exit interview was conducted with Administrator Kathleen Olson. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210408115905

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/22/2021 Section Cited HSC 1569.153(e)	1 2 3 4 5 6 7	1569.153(e) Theft and loss program; standards, property inventories and surrender of personal effects; secured areas. Inventory and surrender of the resident's personal effects and valuables upon discharge to the resident or authorized representative in exchange for a signed receipt. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Administratror agreed to give all residents or their authorized representative the original COVID-19 vaccine card. Facilty shall mail the original card to R1. If the resident prefers that the facility retain the card on file, then the card must be readily available upon request by residents and authorized representatives. Submit a written plan of correction by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and document review, resident (R1) requested the original COVID-19 vaccination card in Feb. 2021, and was only provided a copy. Resident was discharged on 3/1/21. Staff stated due to Administration changes the whereabouts of the cards were unknown for at least one day. R1 later returned to pick-up the card, and was again not given the CDC COVID-19 vaccine index card.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC9099 (FAS) - (06/04)

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