198603163-12-9-2021-28-AS-LHIS-C9RPQB-20211216103049

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603163
Report Date: 12/09/2021
Date Signed: 12/09/2021 12:09:59 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
12/06/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211206090603

FACILITY NAME:	CALIFORNIA MISSION INN - ROSE MANOR		FACILITY NUMBER:	198603163
ADMINISTRATOR:	TYLER CHENEY		FACILITY TYPE:	740
ADDRESS:	4825 EARLE AVE		TELEPHONE:	(626) 287-0438
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	85	CENSUS: 42	DATE:	12/09/2021
		UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Tyler Cheney, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility caused injury to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation. The purpose of the visit was discussed with Administrator Tyler Cheney.

The investigation consisted of the following: A physical plant tour of the facility, record review, and interviews with residents (R2- R7) and staff (S1- S5). Former resident (R1's) Power of Attorney was interviewed. Resident (R1) is deceased and was not interviewed. Resident (R1's) file was reviewed and documents [Identification And Emergency Informatio, Face Sheet, Preplacement Appraisal Information, Resident Appraisal, Physician Reports (7/18/2017, 3/20/2019, 2/25/2020), Medication Review Reports (6/19/2019, 1/28/2020, 7/31/2020), Rx MD orders, LIC 500 Personnel Report, and resident roster] were reviewed and obtained. No health and safety issues were observed during the visit.

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: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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-20211206090603

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 - ROSE MANOR	FACILITY NUMBER: 198603163
	VISIT DATE: 12/09/2021

NARRATIVE

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Allegation: "Facility caused injury to resident." Based on record review and interviews conducted the findings indicate that former resident (R1) had pre-existing Glaucoma disease prior to moving in to the facility on 7/21/2017. Resident (R1) was admitted to the facility with Glaucoma medications [Brimonidine Tartrate Solution, Dorzolamide HCI solution, Theratears Solutions, and Latanoprost Solution. Per Physician's Reports the resident was not diagnosed with Dementia and was not taking anti-psychotic medications during the time it resided at the facility. Resident (R1) had various health issues that were managed with medications ordered by Physician; which were administered as directed. No major combative behaviors by resident (R1) or administration of behavioral medications were reported by staff. Staff denied over-medicating R1.

Staff interviews revealed that resident (R1) was ambulatory and did not appear to have major eye disease issues while it lived at the facility. Staff stated that resident (R1's) daughter/Power of Attorney [POA] took the resident to medical appointments. The resident was discharged from the facility on 8/1/2020, and went to live at another Assisted Living facility closer to family. All staff interviewed denied causing injury to resident (R1) or over-medicating resident (R1). Six (6) out of six (6) residents interviewed denied that facility staff have caused any injuries to residents.

Resident (R1's) Power of Attorney was interviewed and denied the allegation by confirming that R1 had Glaucoma eye disease prior to moving into the facility, and went blind on the left eye because at the beginning of the COVID-19 Pandemic R1 was scheduled to receive laser eye surgery at the Veteran's Affairs Hospital, but due to COVID-19 health setting guidelines the resident's surgery got cancelled, and caused the resident to lose sight in the left eye. Therefore, the facility is not at fault. Record review did not corroborate neglect of care, or injury to resident (R1) during the length of time it resided at the facility.

Based on interviews conducted, records reviewed, and LPA observations there is insufficient information to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted with Administrator Tyler Cheney. A copy of the report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC9099 (FAS) - (06/04)

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