198603426-3-27-2024-28-AS-FFIS-D3STRT-20240328145802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603426
Report Date: 03/13/2024
Date Signed: 03/27/2024 04:17:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
07/07/2022 and conducted by Evaluator Sanjay Vaid

COMPLAINT CONTROL NUMBER: 28-AS-20220707113218

FACILITY NAME:	J AND C HOUSE OF LOVE II		FACILITY NUMBER:	198603426
ADMINISTRATOR:	SMITH, CHANTE		FACILITY TYPE:	740
ADDRESS:	15218 WILDER AVENUE		TELEPHONE:	(562) 706-2128
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 6	DATE:	03/13/2024
		UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Lawrence Santos		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff caused injury to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sanjay Vaid conducted a subsequent complaint visit regarding the allegation and discuss the new findings of the allegation. LPA Vaid met with Caregiver-Lawrence Santos, discussed the purpose of the visit, which was to deliver complaint investigation findings.

The investigation consisted of the following: On 07/08/2022 LPA Margaryan toured the facility, conducted physical plant and environment tour of the facility, residents’ files and other vital documents pertaining to the allegation. Collected copies of R1’s, R2’ & R3’s admissions agreement, preplacement appraisal information, Identification and emergency information, Physician’s report, functional capabilities, home health notes and resident and staff rosters. On 07/15/22, the department interviewed R1s home health agency staff and requested R1 home health records, on 07/27/22, the department contacted the Los Angeles County Fire Department and requested ambulance report and pre-hospitalization records for R1 and requested R1 medical records from Kaiser Permanente. On 09/01/22, the department contacted Los Angeles County Sheriff department to obtain law enforcements report regarding R1s alleged physical abuse.
*****Continued on 9099C*******

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

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-20220707113218

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: J AND C HOUSE OF LOVE II	FACILITY NUMBER: 198603426
	VISIT DATE: 03/13/2024

NARRATIVE

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On todays visit, LPA Vaid interviewed caregivers Lawrence Santos and Liberty Palcone and toured the physical plant with Lawrence Santos and observed the facility to be in good repair. LPA interviewed resident #1 - #6 and staff #1 -#2.
Regarding allegation: Staff caused injury to resident. It is alleged that a resident presented to the emergency department due to a medical condition, and hospital staff observed the resident to have a fractured wrist, pain and swelling, due to physical abuse by staff. The investigation revealed the following: interviews with (6) of (6) resident did not provide any information to support the allegation. Interviews with (2) of (2) staff indicated staff are not aware of a resident being physically abused by staff and staff indicated resident # (R1) complained of abdominal pain on 06/27/22. Staff called 911 and R1 was transported to Kaiser Emergency Department by first responders. Administrator and staff reported they did not observe R1 to have any injuries to R1’s extremities prior to leaving to the hospital. Records review revealed that per R1’s Pre-Hospital Care Report/Los Angeles County Fire Dept. dated 06/27/22, indicated R1’s primary symptoms were abdominal/pelvic pain, and the report did not list any injuries to R1’s extremities. Upon R1s admission to the hospital on 06/27/22, there is no documentation of R1 having sustained a wrist/arm fracture. Per R1’s hospital records, R1s wrist/arm fracture was observed on 06/28/22. The Los Angeles County Sheriff Dept. interviewed R1 on 07/02/22 and R1 did not report being physically abused by facility staff and there was no evidence of elder abuse. As of 03/13/2024 R#1 does not reside at the facility.
Based upon records review and interviews conducted, the findings indicate that, 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 conducted with Lawrence Santos. A copy of the licensing report was provided at time of visit.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC9099 (FAS) - (06/04)

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