198603617-8-13-2024-28-AS-FFIS-D8EUWJ-20240823155647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603617
Report Date: 07/23/2024
Date Signed: 08/13/2024 09:31:54 AM

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
04/11/2023 and conducted by Evaluator Sanjay Vaid

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230411101826

FACILITY NAME:	HOUSE OF GRACE 3		FACILITY NUMBER:	198603617
ADMINISTRATOR:	VILLAR, SHELLA		FACILITY TYPE:	740
ADDRESS:	2178 URSINUS CIRCLE		TELEPHONE:	(626) 716-1033
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 6	DATE:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	02:03 PM
MET WITH:	Administrator, Michelle Aguirre		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility failed to meet residents dietary needs.
Facility failed to communicate with resident's family.
Facility overmedicated resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vaid conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met Michelle Aguirre (Administrator) and explained the reason for the visit.
During last visit on 04/17/2023, LPA Villalobos requested and obtained a copy of the staff and client roster, LPA toured the physical plant, interviewed residents #1-5 (R1-R5) and staff #1-3 (S1-S3). LPA collected documents from R1's file.

On today’s visit LPA Vaid met with the administrator to deliver the findings.
Regarding the allegation: Facility failed to meet resident’s dietary needs. It is alleged the facility kept giving dairy to R1 when she was lactose intolerant. According to the records reviewed, R1 was given a diet that was designed and approved by R1’s physician. The facility made necessary adjustments to the resident meal plans, as reviewed in the records.
CONTINUED ON PAGE 809C

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: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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-20230411101826

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: HOUSE OF GRACE 3	FACILITY NUMBER: 198603617
	VISIT DATE: 07/23/2024

NARRATIVE

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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 allegation is UNSUBSTANTIATED.

Regarding the allegation: Facility failed to communicate with residents’ family. It is alleged that the facility did not properly communicate with the family during issues arising from R1. According to records obtained, R1 responsible party was not aware of any communication issues with the facility. The administrator states, they informed the family of resident whenever there were issues like refusal to take medication, the facility would reach out to the family to see if they could talk her into taking their meds. Random outbursts from the R1, claiming to be soiled when they were not. The facility would inform the family when R1 was having behavior issues and need to talk her down, made notes of R1 progress and behavior changes. 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 allegation is UNSUBSTANTIATED.

Regarding the allegation: Facility over-medicated residents. It is alleged that the facility was over-medicating R1 to keep her quiet. The facility denies this claim. Facility gave the medications that were prescribed to R1 by physician and were given as prescribed and ordered by doctors. Facility noted that combination of different medications prescribed by different doctors were making R1 agitated and forwarded the information to the family. R1's responsible party stated when R1 was taken to Kaiser, the hospital observed R1 was taking different medications from different doctors and felt the combination of those medications were harming R1 and needed a change of prescriptions to meet R1’s medication needs. The family removed R1 from the facility after her hospitalization at Kaiser and placed R1 into new facility. 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 allegation is UNSUBSTANTIATED.

An exit interview was conducted and copy of report was left with the Administrator.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

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