198603585-2-27-2024-28-AS-LHIS-D36USC-20240308145006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603585
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:55:50 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
02/26/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240226121018

FACILITY NAME:	HENRIETTA'S HOME		FACILITY NUMBER:	198603585
ADMINISTRATOR:	AQUINO, ROBIN		FACILITY TYPE:	740
ADDRESS:	131 SEGOVIA AVENUE		TELEPHONE:	(626) 703-4958
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	6	CENSUS: 6	DATE:	02/27/2024
		UNANNOUNCED	TIME BEGAN:	02:33 PM
MET WITH:	Belen Taico, House Manager		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility illegally evicted a resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit in regards to the allegation listed above. LPA discussed the purpose of the visit with House Manager Belen Taico and with telephonically with Administrator Robin Aquino.

The investigation consisted of: A physical plant tour of the facility, record review, Hospital case worker and staff (S1-S4) were interviewed. No residents were interviewed due to cognitive impairment due to Dementia. The following documents were reviewed/obtained: Identification and Emergency Information/Face Sheet, Admission Record, Preplacement Appraisal Information, Resident Appraisal, incident report, Cal Aim Appraisal, Physician's Report, LIC 500 Personnel Report, and resident roster.

***See narrative summary on next page.***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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-20240226121018

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: HENRIETTA'S HOME	FACILITY NUMBER: 198603585
	VISIT DATE: 02/27/2024

NARRATIVE

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Allegation: Facility illegally evicted a resident in care. According to information obtained, the facility moved resident (R1) to a skilled nursing facility (SNF) for an evaluation without responsible party's permission, and the responsible party was under the impression that the resident would be returning to the facility. Based on interviews conducted, Administrator and House Manager stated that resident (R1) often complained of pain and requested to be evaluated by a doctor. Staff stated that R1's responsible party was informed and agreed to the reason for the transfer to the hospital. On January 17, 2024, R1 was transported to Southern California Hospital for an evaluation because of lower extremities and low back pain. According to staff interviews, the hospital MD ordered the resident be transferred to a skilled nursing facility (SNF) because R1 required a higher level of care. The hospital case worker notified House Manager that R1 was not returning to the facility. LPA spoke to Southern California Hospital case worker and it was confirmed that R1 was transferred to a SNF per physician's order.

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.

Exit interview conducted with House Manager Belen Taico. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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