198603538-10-7-2022-28-AS-RORN-CK6VL8-20221013163132

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603538
Report Date: 10/07/2022
Date Signed: 10/07/2022 04:19:30 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
09/29/2022 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220929162920

FACILITY NAME:	ALL IN CAREHOME		FACILITY NUMBER:	198603538
ADMINISTRATOR:	YAMASHIRO, SHELLY		FACILITY TYPE:	740
ADDRESS:	1158 BEAVER WAY		TELEPHONE:	(626) 698-9615
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 5	DATE:	10/07/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Caregiver, Rosalyne Obedoza		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff were not wearing masks.
Facility is not following COVID-19 protocols.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint investigation and to deliver findings for the allegations listed above. Upon arrival, LPA met with Caregivers Edwin Uy and Rosalyne Obedoza and explained the purpose of the visit.

During the initial visit on 10/05/2022, LPA Pena obtained copies of the staff and resident rosters, staff schedules for Sep-Oct 2022, interviewed Staff #1 (S1) and Staff #2 (S2), Resident #1(R1), Resident #2(R2) and interviewed S5 over the phone. LPA also reviewed facility's infection control plan, residents’ files, and vaccination records for S1-S2. LPA observed that S1 who greeted LPA at the door was not wearing mask. S1 did not ask LPA to sign in, use hand sanitizer or asked for temperature check.

During today's visit, LPA obtained the visitors sign in sheet for June-Sep 2022, interviewed Resident #3 (R3) and attempted to interview Resident #4 (R4) and Resident #5 (R5), and requested a copy of the staff training log for the infection control plan.

CONTINUATION ON LIC 9099-C..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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-20220929162920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALL IN CAREHOME	FACILITY NUMBER: 198603538
	VISIT DATE: 10/07/2022

NARRATIVE

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In regards to the allegation "Facility staff were not wearing masks." It was alleged that on 9/29/2022 at 12:30pm, W1 Ombudsman entered facility through front door and observed S2 without a mask. S2 stated only visitors are to wear a mask when entering the facility. S2 did not try to wear a mask despite having two (2) separate conversations regarding masking. During a previous visit by W2 on 6/14/2022, two Staff S3 and S4 were observed not wearing masks and no Covid screening done upon entry for an indoor visit.

On 10/05/2021, LPA conducted an unannounced visit and upon entry into the facility, LPA observed that S1 was not wearing a mask and did not perform the Covid-19 screening protocols: (a) temperature check (b) sign in (c) wash or sanitize hands. Shortly thereafter, S2 arrived at the facility and LPA observed that he was not wearing a mask either and did not wash hands or use hand sanitizer upon entry. LPA also observed R1-R2 not wearing a mask. LPA observed that S1-2 were providing care to the residents unmasked. LPA interviewed S1-2 and both stated that they never wear a mask because they are inside the facility and they did not know it was required. S2 stated that he does not like wearing a mask because it is hard to breathe and only visitors must wear a mask when they enter the facility. LPA attempted to interview R1-2 but both were unable to communicate coherently. LPA interviewed S5 over the phone and stated that she was not aware that the staff do not wear mask inside the facility. S5 indicated that she provides masks for the staff and it is difficult for her to monitor because she is not around every time. S5 stated that she trained the staff regarding Covid-19 screening and protocols but will re-train them. LPA interviewed S3 over the phone who does not work at the facility anymore. S3 acknowledged that he did not wear a mask and conduct the Covid-19 screening when W2 came to visit on 6/14/22 because he forgot. LPA interviewed S4 on the phone and stated she never wear a mask inside the facility.

On 10/07/2022, LPA conducted a subsequent visit and interviewed R3-R5. R3 stated that Staff never wear a mask. R3 also indicated that none of the staff did not wear mask when entering her room to serve food and give medication. R4-R5 who are both cognitively impaired stated that they were not sure and cannot remember if Staff wear mask inside the house. LPA also determined that the facility did not have an in-service training log for Infection Control Plan.

CONTINUATION ON LIC 9099-C...

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220929162920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALL IN CAREHOME	FACILITY NUMBER: 198603538
	VISIT DATE: 10/07/2022

NARRATIVE

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Regarding the allegation " Facility is not following COVID-19 protocols." It was alleged that on 9/29/2022 at 12:30pm, facility Staff did not screen W1 for COVID-19 symptoms until prompted. While staff was attempting to take W1’s temperature, the forehead thermometer was not working properly and needed a change of battery. During a previous visit by W2 on 6/14/2022, two (2) Staff, S3-4 were not wearing masks and did not screen W2 for COVID-19 symptoms upon entry for an indoor visit. LPA conducted an unannounced visit on 10/05/2022 and observed that S1 who greeted LPA at the door did not ask LPA to sign in, use hand sanitizer or asked for temperature check. S1-2 stated that S5 did not conduct a formal training about Covid-19 protocols but reminded them to wear a mask and screen visitors upon arrival. S1-2 both said that they sometimes forget to wear a mask and do covid-19 screening when visitors arrive at the facility. On 10/06/22, S3 stated that he and S4 forgot to wear a mask and do the Covid-19 screening when W2 visited the facility on 6/14/22. LPA interviewed S4 on the phone and she stated that she never wears a mask inside the facility. S4 also indicated that she did not conduct Covid-19 screening at the door for visitors. On 10/07/22, LPA interviewed R3-5 and all of them stated that they do not know if the staff screens the visitors when they arrive because they stay in their respective rooms most of the time. LPA attempted to interview R1-2 but they were not able to communicate effectively.

Based on LPA's observations, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted with Rosalyne Obedoza and a copy of the report, LIC 9099D, and Appeal Rights were provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20220929162920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALL IN CAREHOME	FACILITY NUMBER: 198603538
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/08/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful,and comfortable accommodations, furnishings, and equipment.	1 2 3 4 5 6 7	Licensee shall provide additional training to all staff regarding COVID-19 protocols and about wearing mask indoors and fax the completed in-service training log to CCLD on or before the POCdue date. Note: Staff present during LPA's visit wore a mask throughout their shift. LPA advised all staff present to follow COVID-19 protocol.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LPA observed taht upon entry into the facility, Staff #1-2 were not wearing masks. Witnesses also indicate that during an unannounced visit to the facility on 9/29/22 and 6/14/22, Staff were not wearing masks which posed a potential risk for residents in care.	8 9 10 11 12 13 14
Type A 10/08/2022 Section Cited CCR 87470(c)(1)(F)	1 2 3 4 5 6 7	87470 - Infection Control Requirements..An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.	1 2 3 4 5 6 7	The Administrator will do in-service training for all the staff regarding COVID-19 protocols and symptom screening to all visitors. Administrator will follow the infection control plan and will fax a copy of the completed in-service training signed by all the staff on or before the POC due date.
	8 9 10 11 12 13 14	The requirement is not met as evidenced by: LPA's observations, interviews and records review. LPA observed that staff did not perform the Covid-19 protocols/screening for visitors upon entry to the facility which posed a potential risk for residents in care.	8 9 10 11 12 13 14

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

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