198603617-8-21-2024-28-AS-FFIS-D8EUWH-20240823155647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603617
Report Date: 08/13/2024
Date Signed: 08/21/2024 08:40:28 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

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:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:			TIME COMPLETED:	10:00 AM

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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*** This licensing report issued on 08/13/2024 supersedes that licensing report dated 07/23/24, LPA Vaid obtained additional information, however, the investigation findings will remain the same***

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. Toured physical plant with caregiver Maria Macalino and did not observe any Health and Safety conerns.

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: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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-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: 08/13/2024

NARRATIVE

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Regarding the allegation: Facility failed to meet resident’s dietary needs. It is alleged the facility staff were giving the resident processed food and milk products, and staff were not complying with residents restricted diet, as resident is lactose intolerant. During investigation, LPA interviewed five (5) of five (5) residents, all five residents could not corroborate the allegation. Three (3) of three (3) staff were interviewed and denied the allegation. Hospice services employees could not corroborate this allegation, the hospice staff made visits during non-meal hours. According to the records reviewed, R1 was given a diet that was designed and approved by R1’s physician. Review of Resident #1 (R1) Physicians Report dated 01/27/23 indicates milk and milk product, however the physician report does not indicate R1 is on a modified or R1s diet restricts processed food or milk products. Review or R1 facility file, including R1s hospice care plan dated 03/06/23 indicates that R1 was on a mechanical soft diet and does not mention restriction of processed food or dairy products. The facility made necessary adjustments to R1s meal plan. 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 R1s family regarding issues that arose while R1 resided in the facility. During the investigation, LPA interviewed five (5) of five (5) residents, all five residents could not corroborate the allegation. Three (3) of three (3) staff were interviewed and denied the allegation. Two Hospice staff stated the communication with family was positive, S1 family was able to communicate with hospice services staff regularly. According to LPAs interviews, R1’s responsible party, was not aware of any lack of communication issues between R1s family members and the facility. Interviews with facility staff indicated that the administrator and staff informed R1s family of issues concerning R1, such as R1s refusal to take medications. The facility staff would reach out to the R1s family to see if the family members could talk R1 into taking their meds. R1s would exhibit behaviors, such as random outbursts and claiming to be soiled when R1 was not soiled. The facility would inform R1s family of R1s behavioral issues and R1s family would assist in speaking with R1. Based upon the investigation, interviews with residents and staff, review of R1s facility file, the investigation did not reveal any evidence to support that staff were not communicating with R1s family. 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.

Continued 9099C.......

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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: 08/13/2024

NARRATIVE

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Regarding the allegation: Facility over-medicated residents. It is alleged that the facility was over-medicating R1 to keep R1 quiet. The facility administrator and staff deny the allegation. During the investigation, LPA interviewed five (5) of five (5) residents, all five residents could not corroborate the allegation. Three (3) of three (3) staff were interviewed and denied the allegation. Hospice staff could not corroborate this allegation, the hospice staff was not present during medication administration. Per interviews with facility staff, staff reported that staff gave R1 medications as prescribed by R1s physician. LPAs interview with R1 authorized representative, revealed that when R1 was taken to the hospital, the hospital observed R1 was taking several different types of medications prescribed by different doctors, and felt the combination of those medications were harming R1, therefore, a change of prescriptions was implemented to meet R1’s medication needs. Per R1s authorized representative, R1s was discharged from the hospital, and based on the hospital recommendation, R1s family removed R1 from the facility and placed R1 into new facility. Per review of R1s file, interviews with staff and residents the investigation did not reveal that staff were overmedicating R1 and staff were following R1 physician orders. 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 this report was left with the Administrator Becky Sinclair.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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