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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603285
Report Date: 08/11/2023
Date Signed: 08/16/2023 09:41:11 AM

Substantiated


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
02/02/2022 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220202151529
FACILITY NAME:ST. JUDE'S ELDER CARE IVFACILITY NUMBER:
198603285
ADMINISTRATOR:RAGANO, SCOTTFACILITY TYPE:
740
ADDRESS:536 CHARVERS AVENUETELEPHONE:
(909) 263-3787
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rita Regis (Caregiver)TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility did not obtain medical care for the resident in a timely manner.
INVESTIGATION FINDINGS:
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***LPA Kruz Long amended the original report and redelivered complaint report to the facility. Upon arrival LPA met with Rachelle Jacob (Caregiver) and explained the purpose of the visit.***

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced subsequent complaint visit to the facility in order to deliver complaint investigation findings. LPA met with Rita Regis (Caregiver) and explained the purpose of the visit.

On 02/03/22, LPA Long conducted the initial visit and checked on the health and safety check of the client in care. LPA toured the facility and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Restrooms, handwashing basins, toilets were operable.

On today visit, LPA Long delivered complaint investigation findings.
The investigation consisted of the following, interviews with Administrator, staff #1- #2, resident # 1 - #4, resident #1 family member, witness #2, review of resident #1 facility file, including 01/25/22 incident report. Continue to LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
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 5
Control Number 28-AS-20220202151529
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: ST. JUDE'S ELDER CARE IV
FACILITY NUMBER: 198603285
VISIT DATE: 08/11/2023
NARRATIVE
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***LPA Kruz Long amended the original report and redelivered complaint report to the facility. Upon arrival LPA met with Rachelle Jacob (Caregiver) and explained the purpose of the visit.***

Regarding allegation: Facility did not obtain medical care for the resident in a timely manner. The allegation, resident #1 fell in the facility and resident #1 sustained injury to head in the form of bruises and bumps and staff returned resident #1 to bed and did not seek timely medical attention for resident #1. Interviews with 3 of 3 staff revealed that the Administrator and staff were aware resident #1 had an unwitnessed fall in the facility on 01/25/22 and sustained a laceration to residents’ cheek and a bruise on the forehead. Administrator reported that resident #1 was not taken to the hospital due to resident #1 family member did not want resident #1 to be taken to the hospital and resident #1 injuries were not life threatening. Staff assisted resident #1 by applying antibiotic cream and ice to the bruises, however, staff did not seek medical attention for resident #1 injuries. Interview with 3 of 4 residents revealed that staff assist resident as needed and residents deny any injuries and do not have any concerns regarding the staff. Resident #1 Family Member #1 reported staff called resident #1 family member on the morning of the incident to notify resident #1 family member of the fall and injury, however, the staff did not report the severity of the injury to family member #1. Several hours later, family member #1 visited the facility and observed resident #1 injury to be more severe that staff reported earlier that day. Interviews with witness #2 revealed that resident #1 fell in the facility and sustained a laceration and bruises on resident #1 face and facility staff did not seek timely medical attention for resident #1. Resident#1 was interviewed by IB investigator Zertuche and denied falling in the facility and reported being hit by a staff, however, resident could not provide any further details regarding the staff and/or incident.

Based upon the information obtained during the complaint investigation, the investigation revealed resident #1 had an unwitnessed fall on 01/25/22 and sustained injuries to resident #1 head: a laceration to resident face/eye area and bruises to resident #1 forehead. Facility staff were aware of resident #1 injuries and notified resident #1 family member around 9:30AM on the day of the injury, resident #1 family member visit the facility a few hours later and observed resident#1 injuries to be more severe that reported by staff, therefore, staff has knowledge of resident #1 injury on 01/25/22 and failed to seek timely medical attention for resident #1 injuries. Based on the department’s investigation, interviews with staff and residents and review of resident#1 file, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted with Rita Regis (Caregiver) and a copy of this report and appeal rights provided.

During visit, immediate Civil Penalties were issued to licensee in the amount of $500.00.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220202151529
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: ST. JUDE'S ELDER CARE IV
FACILITY NUMBER: 198603285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/12/2023
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs......
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Licensee shall review this Title 22 regulation and provide additional training to all Staff to seek timely medical attention if need for future incidents of similar nature and provide proof of training to the department by the POC date.
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This requirement is not met as evidenced by: Resident #1 had an unwitnessed fall on 01/25/22 and sustained injuries to resident #1 head: a laceration to resident and staff failed to seek timely medical attention for resident #1 injuries.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/02/2022 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220202151529

FACILITY NAME:ST. JUDE'S ELDER CARE IVFACILITY NUMBER:
198603285
ADMINISTRATOR:RAGANO, SCOTTFACILITY TYPE:
740
ADDRESS:536 CHARVERS AVENUETELEPHONE:
(909) 263-3787
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rita Regis (Caregiver)TIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
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9
Staff person hit the resident in the face.
Resident sustained unexplained bruising due to lack of care and supervision.
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
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9
10
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13
***LPA Kruz Long amended the original report and redelivered complaint report to the facility. Upon arrival LPA met with Rachelle Jacob (Caregiver) and explained the purpose of the visit.***
Licensing Program Analyst (LPA) Kruz Long conducted an unannounced subsequent complaint visit to the facility in order to deliver complaint investigation findings. LPA met with Rita Regis (Caregiver) and explained the purpose of the visit.

On 02/03/22, LPA Long conducted the initial visit and checked on the health and safety check of the client in care. LPA toured the facility and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Restrooms, handwashing basins, toilets were operable.

On today visit, LPA delivered complaint investigation findings.
The investigation consisted of the following, interviews with Administrator, staff #1- #2, resident # 1 - #4, resident #1 family member witness #2, review of resident #1 facility file, including 01/25/22 incident report. Continue to LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220202151529
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: ST. JUDE'S ELDER CARE IV
FACILITY NUMBER: 198603285
VISIT DATE: 08/11/2023
NARRATIVE
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Regarding allegation: Staff person hit the resident in the face. Per the allegation, resident #1 fell in the facility and reported being hit in the face by a staff member. Resident #1 sustained injury to head in the form of bruises, bumps, and laceration to the face. Interviews with 3 of 3 staff revealed that the Administrator and staff were aware of resident #1 had an unwitnessed fall in the facility on 01/25/22 and sustained a laceration to residents’ cheek and a bruise on the forehead. Staff assisted resident #1 by applying antibiotic cream and ice to the bruises. Administrator and staff did not have knowledge residents with any unexplained bruises and staff denied hitting resident #1 and staff denied staff having any knowledge of staff hitting facility residents. Interview with 3 of 4 residents revealed that staff assist resident as needed and residents deny any injuries, do not have any concerns regarding the staff and were not aware of residents with unexplained bruising or staff hitting residents. Facility staff notified resident #1 family member in the morning on the day of the incident, 01/25/22. . Resident #1 was interviewed by IB investigation Zertuche and denied falling in the facility and reported being hit by a staff, however, resident #1 could not provide any further details regarding the staff and/or incident. Based on the department’s investigation, interviews with staff and residents, witnesses, including resident #1 and records review, investigation did not reveal any evidence to support the allegation. 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.

Regarding allegation: Resident sustained unexplained bruising due to lack of care and supervision. Per the allegation, resident #1 fell in the facility and reported being hit in the face by a staff member. Resident #1 sustained injury to head in the form of bruises, bumps, and laceration to the face. Interviews with 3 of 3 staff revealed that the Administrator and staff were aware of resident #1 had an unwitnessed fall in the facility on 01/25/22 and sustained a laceration to residents’ cheek and a bruise on the forehead. Staff assisted resident #1 by applying antibiotic cream and ice to the bruises. Administrator and staff did not have knowledge residents with any unexplained bruises and staff denied hitting resident #1 and staff denied having knowledge of staff hitting facility residents. Interview with 3 of 4 residents revealed that staff assist resident as needed and residents deny any injuries, do not have any concerns regarding the staff and were not aware of residents with unexplained bruising or staff hitting residents. Facility staff notified resident #1 family member in the morning on the day of the incident, 01/25/22. Resident#1 was interviewed by IB investigation Zertuche and denied falling in the facility and reported being hit by a staff, however, resident #1 could not provide any further details regarding the staff and/or incident. The investigation did not reveal resident with any unexplained bruises due to lack of care and supervision. Based on the department’s investigation, interviews with staff and residents, including resident #1 and record review, investigation did not reveal any evidence to support the allegation. 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.

Based on the department's interviews and record review, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with Rita Regis (Caregiver) and a copy of this report provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5