198603169-6-6-2022-28-AS-MVAO-CFDP59-20220614110021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603169
Report Date: 06/06/2022
Date Signed: 06/06/2022 12:28:52 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
07/08/2020 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200708105822

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: 4	DATE:	06/06/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Staff / Jay Choi Administrator / Jung Hyun "Eunice" Kim		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff abandoned resident at hospital.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Staff abandoned resident at hospital". Upon arriving at the facility, LPA met with Staff / Jay Choi and was later joined by the Administrator / Jung Hyun "Eunice" Kim who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility (telephonically) on 7/16/20, in reference to the allegation listed above. The investigation consisted of interviews of various persons to include the Administrator, Staff 1 (S1) and Social Worker from Kaiser Baldwin Park. LPA was unable to interview Resident 1 (R1) as R1 expired on 7/5/20. Also, copies of the following documents were obtained and reviewed in reference to R1;

• Physician's Report • Unusual Incident/Injury Report / LIC 624 • Death Report • Prior Hospital Records from Kaiser Baldwin Park dated 6/10/2020
(Please see LIC 9099C for additional information)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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-20200708105822

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: 06/06/2022

NARRATIVE

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The investigation revealed the following;
Allegation: Staff abandoned resident at hospital. The details of this allegation states that R1 was dropped off on the curb at the hospital in her wheelchair in an "altered state and confusion". No one signed R1 into the hospital and no one was with the resident.

Based on interviews conducted, LPA learned that on 7/3/2020, R1 was having abdominal pain and requested to be transported to the hospital for an evaluation. The Administrator contacted the Social Worker at Kaiser, and was provided a list of transportation companies to contact and schedule a pick up for R1. Arrangements were made by the Administrator to have R1 transported to Kaiser Baldwin Park (KBP) around 4pm, using a third party transportation company authorized by Kaiser. According to the Administrator, the transportation company (name unknown) transported R1 to KBP and the Administrator along with S1 went separately using the Administrator's personal vehicle. The Administrator was unable to ride with R1 due to the situation surrounding the Coronavirus Disease 2019. The Administrator provided R1's information to the driver so that the driver could have R1 checked in upon arriving at KBP. The Administrator also contacted the Social worker at Kaiser and notified them that R1 was on her way to the ER. The Administrator along with S1 arrived at KBP approximately 10 minutes after R1 and R1 had already been checked in and being assisted inside the ER. LPA conducted an interview with the Social Worker at Kaiser and was unable to obtain details regarding R1's drop off and admission to the ER. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the allegation of Staff abandoned resident at hospital. There is insufficient evidence to support this allegation to be true.

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 and a copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC9099 (FAS) - (06/04)

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