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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603302
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:48:01 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
06/03/2022 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220603150115
FACILITY NAME:SUMMIT VIEW HOME CAREFACILITY NUMBER:
198603302
ADMINISTRATOR:CASTRO, SILVIAFACILITY TYPE:
740
ADDRESS:107 CLEARVIEW CREST DRTELEPHONE:
(909) 396-7839
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 4DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Administrator, Silvia CastroTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is not giving resident their supplements.
Resident is receiving incorrect medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Administrator, Silva Castro and explained the reason for the visit.

The investigation consisted of the following: Interviews were conducted with Administrator, Resident #1's (R1's) family and attempted to interview R1. R1's records were also reviewed.

The investigation revealed the following: Regarding allegation that facility is not giving resident their supplements, R1's medications were reviewed. R1's Medication Administration Record (MAR) and hospice medication records did not list any supplements and there were no physician's orders found for supplements. R1's family was interviewed and family did not have any concerns about supplements not being provided. Administrator indicated R1 is not taking any supplements at this time. An interview was attempted with R1, however R1 was unable to respond to questions. Based on the information obtained, the allegation is unsubstantiated.
Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
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 2
Control Number 28-AS-20220603150115
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: SUMMIT VIEW HOME CARE
FACILITY NUMBER: 198603302
VISIT DATE: 06/09/2022
NARRATIVE
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Regarding allegation resident is receiving incorrect medication, R1's medication and medication records were reviewed. All medications present in the facility are documented properly and there were no medications missing. R1's family had no concerns about the medication given at the facility and reported being happy with the care being provided. Based on the information obtained, the allegation is unsubstantiated.

Although the allegations may have happened or are 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 held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2