198603169-1-12-2022-28-AS-MVAO-CCBTHH-20220308134445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603169
Report Date: 01/12/2022
Date Signed: 01/12/2022 12:54:57 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
01/05/2022 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220105154340

FACILITY NAME:	HOPE HOME CARE FOR ELDERLY		FACILITY NUMBER:	198603169
ADMINISTRATOR:	KIM, JUNG HYUN		FACILITY TYPE:	740
ADDRESS:	23916 HIGHLAND VALLEY RD		TELEPHONE:	(909) 217-2011
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 1	DATE:	01/12/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	S-1/Facility Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident fell while in care.
Staff did not administer resident's medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial 10-day complaint visit to investigate the above allegations. LPA met with S-1/Facility Administrator and discussed the purpose of today's visit.
During this investigation, the following occured: LPA obtained a copy of the Staff schedule, list of Resident(s), reviewed Resident #1 (R-1) and Resident #2 (R-2) files and obtained relevant documentation, interviewed Staff#1/Facility Administrator (S-1) and Staff #2 (S-2). LPA attempted to interview R-1 via telephone and was unable as R-1 did not understand LPA's interview questions. LPA also interviewed R-1's family member via telephone. LPA attempted to interview Resident #2 (R-2) and was unable as R-2 has Dementia. R-1 is unconserved and does not a Power of Attorney, therefore Staff did not release any confidential information on R-1 to family members. Staff and R-1's family member interviews revealed that R-1 independently moved into this facility and resided at this facility from 12/28/2021 through 01/03/2022. Per Staff interviews, R-1 decided to move out of this facility on 01/03/2022 and took belongings and medication and moved back with R-1's family member. R-1's family member also confirmed this information. Per S-1/Facility Administrator, copies of the signed documents were provided to R-1. Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

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-20220105154340

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: HOPE HOME CARE FOR ELDERLY	FACILITY NUMBER: 198603169
	VISIT DATE: 01/12/2022

NARRATIVE

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Allegation: Resident fell while in care. During this investigation, LPA reviewed Resident #1 (R-1) and Resident #2 (R-2) files and obtained relevant documentation, interviewed Staff#1/Facility Administrator (S-1) and Staff #2 (S-2). LPA attempted to interview R-1 via telephone and was unable as R-1 did not understand LPA's interview questions. LPA also interviewed R-1's family member via telephone. LPA attempted to interview Resident #2 (R-2) and was unable as R-2 has Dementia. Staff interviews revealed R-1 did not fall while in care at this facility. Staff interviews revealed that R-1 resided at this facility from 12/18/2021 through 01/03/2022. Per Staff interviews, R-1 decided to move out of the this facility on 01/03/2022 and took belongings and medication. Interviews conducted do not corroborate this allegation.

Allegation: Staff did not administer resident's medication. During this investigation, LPA reviewed Resident #1 (R-1) and Resident #2 (R-2) files and obtained relevant documentation, interviewed Staff#1/Facility Administrator (S-1) and Staff #2 (S-2). Staff interviews revealed Staff administered R-1's medication as prescribed and did not provide R-1 with another Resident's medication. Copies of the Medication Administration Record (MAR's) for R-1 and R-2 were provided for December 2021 through January 2022. LPA attempted to interview R-1 via telephone and was unable as R-1 did not understand LPA's interview questions. LPA also interviewed R-1's family member via telephone. LPA was unable to interview Resident #2 (R-2) as R-2 has Dementia. Interviews conducted and file review do not corroborate this allegation.

Based on LPA's interviews conducted the preponderance of evidence standard has been met, therefore the allegation(s) are UNSUBSTANTIATED.

Exit interview was conducted, a copy of this report and Appeal Rights were provided to S-1/Facility Administrator.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

LIC9099 (FAS) - (06/04)

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