198603163-10-27-2022-28-AS-MVAO-CKYTE8-20221108133928

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603163
Report Date: 10/27/2022
Date Signed: 10/27/2022 04:49:16 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
04/15/2020 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200415133935

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: 37	DATE:	10/27/2022
		UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Ruby Magao, Wellness Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff threatens resident with eviction while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate and deliver findings on the above allegations. The purpose of the visit was discussed with Wellness DIrector Ruby Magao.

The investigation consisted of: On 4/21/2020, due to Coronavirus Disease 2019 (COVID-19) LPA Elizabeth Irra initiated a telephonic complaint investigation with former Administrator Lori Waters. The following documents were requested, but not obtained: Resident and staff rosters including contact information, a list of Residents that have receive an eviction notice in the past 3 months. R-1's: Face Sheet with contact information, Admission Agreement including any addendums, Appraisal Needs and Services Plan (most current), Daily Notes (if applicable) and Physician Report (most current). Staff records-schedule for March 2020 and April 2020, Staff contact numbers, Staff training on Mandating Reporting and Resident Rights. During today’s visit, additional documents (financial/transaction records) and other pertinent documents were obtained. Staff (S2 – S6) and family member (F1) were interviewed.

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: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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-20200415133935

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: 10/27/2022

NARRATIVE

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Allegation: Staff threatens resident with eviction while in care. It is alleged resident (R1) was threatened by former Administrator Laura "Lori" Waters with an eviction due to disagreements and arguments about rent billing and overcharges. Former Administrator stated that resident (R1) was belligerent with everyone after consuming alcohol. According to former Administrator, the resident was told it has the right to consume alcohol, but if it continued to drink excessively and break house rules then an eviction notice may have to be issued. Ms. Waters denied threatening the resident or issuing an eviction notice. A total of six (6) staff were interviewed, one staff (1) staff stated that former Administrator threatened R1 with an eviction in a passive aggressive manner, but never issued an eviction. Family (F1) was interviewed and stated that R1 often addressed staff aggressively when spoken to about it's alcohol use. There is insufficient evidence to corroborate the allegation.

Based upon interviews conducted and record review, the findings indicate that 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 is Unsubstantiated.

An exit interview was conducted with Wellness Director Ruby Magao. 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: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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