198603163-8-9-2022-28-AS-MVAO-CHDSPA-20220817140249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603163
Report Date: 08/09/2022
Date Signed: 08/09/2022 03:39:33 PM

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
12/07/2020 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201207134150

FACILITY NAME:	CALIFORNIA MISSION INN - ROSE MANOR		FACILITY NUMBER:	198603163
ADMINISTRATOR:	LOPEZ, GINA		FACILITY TYPE:	740
ADDRESS:	4825 EARLE AVE		TELEPHONE:	(626) 287-0438
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	85	CENSUS: 40	DATE:	08/09/2022
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Staff #1: Ruby Racca-Magao, Wellness Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff are failing to address a resident's needs while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Ruby Racca-Magao, Wellness Director); as current Administrator (A2: Scott Ambrose) was unavailable at the time of this visit. LPA/RA Ceniceros spoke to S1 prior to entering the facility to conduct a risk assessment. A1 informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. An initial 10-Day virtual visit was conducted by LPA Nicol Wesley on 12/16/20 (via telephone) with (former) Administrator (A1: Lorie Waters) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed two (2) staff members (between 12:30 p.m. - 1:00 p.m. and four (4) residents (between 1:00 p.m. - 2:00 p.m.); reviewed Resident #1's records (between 12:15 p.m. - 12:30 p.m.) and requested copies of pertinent documents: Admissions Agreement, Physician’s Report, Emergency I.D. & Information, Pre-Placement Appraisal, Resident Appraisal, Needs & Services Plan, Staff & Resident Rosters.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

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-20201207134150

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: 08/09/2022

NARRATIVE

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Regarding Allegation #1: this investigation revealed that Resident #1 has a private caregiver that tends to its activities of daily living in addition to facility staff meeting Resident #1's care needs. Resident #1 feels that whenever its done with its meals (breakfast, lunch, and dinner) and would like for its plate to be removed from its room, Resident #1 summons the caregiver to its room following meal time. Resident #1 feels that it takes the caregiver awhile to respond to the resident's room. Resident #1 is satisfied with the overall service from staff providing adequate care and meeting its needs of activities of daily living. The majority of interviews conducted with residents were consistent with their response that the facility is providing adequate care to meet the needs of the residents; and, facility staff respond to the residents calls in a timely manner. Interviews that were conducted of facility staff, the majority indicated that they had not received a complaint from a resident that facility staff is not providing adequate care to a resident. LPA/RA Ceniceros attempted interviews with Reporting Party and Witness #1, but to no avail. A review of Resident #1's records (dated 09/13/17) documented the resident is ambulatory and capacity for self-care: needs assistance with bathing.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE: Staff are failing to address a resident's needs while in care is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Staff #1: Ruby Racca-Magao, Wellness Director.

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC9099 (FAS) - (06/04)

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