198603631-7-7-2023-28-AS-RORN-CW4U8V-20230928152210

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603631
Report Date: 07/07/2023
Date Signed: 07/07/2023 01:38:13 PM

Unsubstantiated

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
06/30/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230630104521

FACILITY NAME:	ST. SEBASTIAN'S HOME FOR THE ELDERLY		FACILITY NUMBER:	198603631
ADMINISTRATOR:	MCGEE, BRIANA		FACILITY TYPE:	740
ADDRESS:	3203 E CAMERON AVE		TELEPHONE:	(626) 222-2641
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	6	CENSUS: 5	DATE:	07/07/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Briana McGee		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not meet resident's incontinence needs
Staff did not properly supervise resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 Jess Cafuri who allowed entry into the facility and was later met by Administrator Briana McGee who assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed administrator, Staff#1 and #2 (S1-S2), two residents (R2-R3) and attempted to interview three residents (R4-R6) in the facility. LPA also interviewed Staff#3 and #4 (S3-S4) via telephone and obtained copy of R1's documents including pre-appraisal and incident reports dated on 6/20/23 and 6/28/23.

(See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20230630104521

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: ST. SEBASTIAN'S HOME FOR THE ELDERLY	FACILITY NUMBER: 198603631
	VISIT DATE: 07/07/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed of the following: Allegation#1 "Staff do not meet resident's incontinence needs" LPA interviewed residents and stated that staff are able to meet their needs. They were always clean and staff are checking on them regularly to ensure they are safe. LPA interviewed staff and reported they assisted residents to take shower every day if they want to. The also change residents' diapers three times a day or as needed. They would also check on them every hour if they stay in their room. For R1, Administrator and staff reported R1 was very agitated and aggressive. R1 liked to remove the diaper and put hands into the diaper. For the particular incident, R1 took diaper off after bowel movement, and spread the feces all over the room including the R1's body, bed, blanket, pillow and floor. Staff did the regular room check and saw R1 and cleaned R1 immediately and attempted to take R1 to shower but R1 was very aggressive, moved around and refused to take shower, therefore staff only cleaned R1 with bed bath and cleaned the room and changed the bed sheet, pillow and everything. During today's visit, LPA observed all the residents are clean and in good hygiene and the residents' room are clean and no odor.

Allegation#2 " Staff did not properly supervise resident" LPA interviewed residents and residents reported they all feel safe living in the facility and staff are supervising them well. LPA interviewed staff and reported they did room check regularly like every hour and ensure residents are safe and clean. According to the administrator and staff, R1 always attempted to stand up from the wheelchair or bed but R1's leg was very weak. R1 cannot even stand well. About R1's fall incident, staff reported it was happened around mid-night and heard some noises from R1's room and went to check and saw R1 attempted to get out of bed but R1 slid out of bed and lean on the bed and wall. The staff immediately assessed R1 to see if R1 had any injury. After the assessment, R1 did not have any injury and staff picked R1 up and put R1 back to bed.

Based on the observation, interviewed conducted with staff and residents and documents review, Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of the report and appeal right was provided to the administrator Briana McGee.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2