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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603163
Report Date: 02/16/2023
Date Signed: 02/23/2023 10:02:48 AM

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
01/15/2021 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210115160840
FACILITY NAME:CALIFORNIA MISSION INN - ROSE MANORFACILITY NUMBER:
198603163
ADMINISTRATOR:LOPEZ, GINAFACILITY TYPE:
740
ADDRESS:4825 EARLE AVETELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 40DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Ruby Magao, Wellness DirectorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff had inappropriate interaction with the resident.
Facility does not have activities.
Food Service inadequate.
Staff share personal information of resident.
Residents are forced to stay in their rooms.
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 the following: On 1/22/2021, a virtual physical plant tour of kitchen area/food preparation station was conducted at 4:25 pm via FaceTime, and staff (S1-S3) were interviewed. The following documents were obtained: COVID Plan of Action [ Letters to family/visitors (4/8/20 & 4/25/20) regarding visitation restrictions and infection control], incident reports RE: COVID-19 positive case dated 1/3/2021 & incident dated 1/13/2, Food Menu [Dec. 2020 – Jan.2021], Alternative Food Menu, (R1's) MD food order, staff compliance training - HIPAA training, Compliance and Code of Conduct proof of completion by receptionist staff, and LIC 500 Personnel Report. On 10/22/2022, residents (R1-R3) and staff (S4) were interviewed. During today's visit, residents (R4- R9) were interviewed.

See LIC 9099C for report continuation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
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-20210115160840
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: 02/16/2023
NARRATIVE
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Allegation: Staff had inappropriate interaction with the resident. It is alleged that on 1/13/2021, two staff were antagonistic and yelled at resident (R1) and it's visitor for questioning COVID-19 visitation policies and for not wearing a mask. The resident went to the front entrance to pick up the food delivery packages that were dropped off by the visitor. Staff explained to the visitor that they were not allowed to enter the building due to pandemic visitation restrictions. Based on interviews conducted, R1's visitor argued with receptionist staff for not allowing R1 to exit the building to get the food delivery. According to staff interviews, R1 and it's visitor were not wearing a required face mask. As a result, staff brought it to their attention and explained that masks are required due to active COVID-19 cases in the building. All staff interviewed denied yelling at R1 and it's visitor. They stated that in the beginning of January 2021 the facility had a COVID-19 outbreak and visitation was prohibited due to the state and public health order. At that time, all residents were quarantined in their rooms, but resident (R1) occasionally sneaked out of the room to see visitors. Resident (R1) denied that both staff involved in the incident yelled at the resident, but stated that the receptionist staff shouted at the visitor when explaining the visitation policies. Staff (S3) was nearby and stated that receptionist staff (S5) did not yell at R1 or the visitor. Staff (S5) was not interviewed due to scheduling conflict, as they only worked at the facility once a week at that time. Staff (S5) is no longer employed at the facility. A total of nine (9) residents were interviewed; all denied the allegation.

Allegation: Facility does not have activities. It is alleged that the facility did not have any scheduled activities for residents during COVID-19 quarantine in 2020 and early 2021. According to record review and staff interviews, the findings indicate the facility had a large COVID-19 outbreak in the building in late December 2020 and January 2021. Due to state and public health directives, residents were to quarantine in their rooms and all communal activities were suspended. All staff stated there were no activities for residents at that time, with the exception of Zoom doctor and family communication. A total of nine (9) residents were interviewed, all stated activities were suspended due to the pandemic. Residents understood the public health directive the facility enforced.

Allegation: Food Service inadequate. It is alleged that the food that was delivered to residents in their rooms in 2020 and early 2021 was poor quality and were given less food selection. Resident (R1) requires a special diet and was not being given variety of foods. Staff interviews revealed that the food was cooked at the sister facility in the same campus and then brought over to this facility. It was transported in carts in disposable food containers in order to prevent virus contagion. Staff stated that the food may have been at times served cold because of staffing shortages experienced during that time; in which caregivers were expected to deliver the food and feed the residents as well. Two (2) out of nine (9) residents stated the food was served lukewarm and the food was not of good quality. According to staff interviews, residents were provided special diet meals as directed. There is insufficient evidence to corroborate the allegation.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210115160840
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: 02/16/2023
NARRATIVE
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Allegation: Staff share personal information of resident. It is alleged that facility staff were revealing personal resident information to other residents and family members about a resident that passed away from the COVID-19 virus. All staff stated denied the allegation and stated that staff are trained not to share any resident personal information with anyone. Staff stated that R1's nearby neighbor was transported to the hospital during the COVID-19 January 2021 outbreak, and residents may have observed through their windows emergency personnel take the resident. Resident (R1) state that they felt the facility did not provide any information about what was happening. Eight (8) residents denied the allegation. Front desk staff or Activities staff handle all resident memorials and place flowers in the lobby with a "in loving memory" message, for other residents to see. According to staff, R1 often asked staff about what was happening in the facility, especially after hearing ambulances. Staff denied sharing any information with residents.

Allegation: Residents are forced to stay in their rooms. It is alleged residents were forced to stay in their rooms beginning November 2020 because the other Assisted Living facility in the front area of the campus had large COVID-19 outbreaks. All staff confirmed that residents were quarantined in their rooms due to COVID-19 outbreak public health orders, and in effort to mitigate the spread of the virus in this building. Staff stated that on several occasions R1 sneaked in family visitors when front desk staff were not present. According to staff interviews, some residents were allowed to go out of their rooms if they were experiencing a lot of anxiety, and that R1 was allowed to walk downstairs to see family visitor. Resident (R1) stated residents were asked to stay in their rooms during COVID-19 pandemic. All residents interviewed stated they were directed to quarantine in their rooms during COVID-19 pandemic outbreaks. Therefore, the allegation cannot be supported because the facility was following public health and Licensing directives.

Based on interviews conducted and record review, there is insufficient information to support the allegations. Although the allegations 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.

Exit interview conducted with Wellness Director. A copy of the report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3