198603161-5-21-2024-28-AS-LHIS-D5VNAP-20240603101748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603161
Report Date: 05/21/2024
Date Signed: 05/21/2024 04:09:01 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
05/14/2024 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240514104301

FACILITY NAME:	CALIFORNIA MISSION INN		FACILITY NUMBER:	198603161
ADMINISTRATOR:	DWIGHT DUNAGAN		FACILITY TYPE:	740
ADDRESS:	8417 MISSION DR		TELEPHONE:	(626) 287-0438
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	85	CENSUS: 16	DATE:	05/21/2024
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Heather Cummings, Maria Cruz and Ron Hipolito		TIME COMPLETED:	04:19 PM

ALLEGATION(S):

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Staff do not provide resident with activities.
Staff isolates resident while in care.
Resident is left in soiled diapers for an extended period of time.
Staff are not meeting resident's toileting needs.
Staff do not ensure that resident has clean linens.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to facility to investigate the above allegations. LPA met with staff Heather Cummings and Maria Cruz. Rhon Hipolito, Executive Director arrived a short time later and assisted with the visit.

The investigation consisted of LPA interviewing six (6) staff, two (2) residents and attempted to interview 4 other residents, taking a tour of facility including all the rooms and common areas in memory care section of facility. LPA reviewed and obtained copies of staff and residents rosters, R1 Medication Review Report, R1 Service Plan Review updated 05/21/2024, R1 Emergency Contact Information, R1 appraisal dated 04/18/2024, R1 Admission Agreement. R1 Task List Schedule for May 2024. R1 Physicians Report For Residential Care facilities for the Elderly (RCFE) dated 05/21/2024, R1 Hospice - Vitas Health Care Physician Recertification dated 02/28/2024, R1 Vitas Addendum Plan of care dated 2/24/2024, AR change form dated 4/18/24, Vitas case sheet dated 04/04/2024
(continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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 3

Control Number 28-AS-20240514104301

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: CALIFORNIA MISSION INN	FACILITY NUMBER: 198603161
	VISIT DATE: 05/21/2024

NARRATIVE

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The investigation revealed:

Allegation: Staff do not provide resident with activities. It is alleged that resident is not included or encouraged to participate in activities.
LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. LPA interviewed two (2) residents and one (1) of two (2) could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. R1 reported that staff never ask R1 to join in activities. S4 reported that S4 always encourages R1 at least 3 times for each daily activity to join in the activities but refuses. LPA observed S4 encouraging R1 to join in activities and R1 refused which is R1 right. LPA observed many residents participating in different activities during different times of visit. There is insufficient evidence to prove the alleged allegation.

Allegation: Staff isolates resident while in care. It is alleged that resident is isolated by staff.
LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. R1 stated R1 likes to be alone and enjoys staying in R1 room listening to music. Staff reported that they encourage resident to leave room several times daily but refuses. There is insufficient evidence to prove the alleged allegation.

Allegation: Resident is left in soiled diapers for an extended period of time. It is alleged that resident is left in soil diapers. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. Staff provided a task log to LPA that documents when diapers are changed and it is consistent with care plan. Staff stated that they will deviate from scheduled diaper change and provide service earlier than scheduled if needed. LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. LPA toured all the rooms in memory care and no room or common area had foul odors or evidence that residents are left in soil diapers. There is insufficient evidence to prove the alleged allegation.

Allegation: Staff are not meeting resident's toileting needs. It is alleged that resident is not being assisted in toileting needs. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. Staff provided a task log to LPA that documents when personal care is provided and it is consistent with care plan.
(continued)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20240514104301

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: CALIFORNIA MISSION INN	FACILITY NUMBER: 198603161
	VISIT DATE: 05/21/2024

NARRATIVE

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LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. There is insufficient evidence to prove the alleged allegation.

Allegation: Staff do not ensure that resident has clean linens.
LPA interviewed six (6) staff and 6 of 6 staff denied the allegations. LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. S3 reported that S3 is responsible to change the linens in all the resident's rooms once per week. S3 stated S3 will change the linens more frequently if they get soiled before the scheduled day. S3 stated that someone changed R1 linens today and S3 does not know who. LPA asked S3 to show LPA R1 linen that had just been changed and LPA observed it to be clean and dry. 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 Executive Director Rhon Hipolito. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC9099 (FAS) - (06/04)

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