306004767-7-12-2022-22-AS-MVAO-CHSTAZ-20220830143422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004767
Report Date: 07/12/2022
Date Signed: 07/12/2022 11:06:37 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2020 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200909130749

FACILITY NAME:	ABOVE ALL CARE 2		FACILITY NUMBER:	306004767
ADMINISTRATOR:	SHELLY YAMASHIRO		FACILITY TYPE:	740
ADDRESS:	1255 BERING STREET		TELEPHONE:	(310) 994-9181
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 5	DATE:	07/12/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Licensee Nicholas Oudinot		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff are not adequately supervising residents
Staff are retaliating against the resident.
Staff are not conducting medication management
Administrator is not reporting resident falls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michelle Reed met with Licensee Nicolas Oudinot to discuss the complaint findings for the above allegations. The investigation consisted of interviews with Administrator, staff and witnesses as well as documentation from the facility. Due to the residents cognitive skills they were not able to be interviewed. The following was determined:

Staff are not adequately supervising residents.

Resident #1(R1) moved into the facility on 11/19/19. R1 is Non-ambulatory, has Dementia and needs assistance with all Activities of Daily Living. R1 has a tendency to get angry when things do not go her way and will yell, scream and throw things. Staff stated that they redirect R1 when she yells and throws tantrums and R1 has never been physically aggressive and hurt other residents. A review of records disclosed that R1’s behaviors have been brought to the attention of R1’s Doctor’s for solutions.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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 22-AS-20200909130749

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ABOVE ALL CARE 2	FACILITY NUMBER: 306004767
	VISIT DATE: 07/12/2022

NARRATIVE

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Staff are retaliating against the resident

On 9/4/20, R2 was observed by staff wandering around the house and entering other residents’ rooms. Staff kept having redirect her due to Covid precautions. Administrator notified R1’s POA via incident report. According to Administrator it was done for reporting purposes only not retaliation.

Staff are not conducting medication management

According to staff interviewed, R2 did not get her medications on 9/3/20 as she had hid them in a napkin. Staff found the pills in the napkin. Staff immediately brought it to the attention of the Administrator who in turn notified the POA.

Administrator is not reporting falls

According to the Reporting Party, R1 had a fall sometime in early May. Interviews with staff did not disclose a fall by R2 and no unusual incident report was reported to Licensing regarding a fall. Interviews also did not disclose that R1 had pushed R2.

Based upon interviews, the allegation are unsubstantiated, meaning that 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. Licensee and Administrator are reminded of Reporting Requirements and the use of an LIC624.

An exit interview was conducted and a copy of this report was provided to Licensee Nicolas Oudinot.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC9099 (FAS) - (06/04)

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