306005335-5-22-2020-22-AS-SSAS-BQ3M2D-20200529091322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005335
Report Date: 05/22/2020
Date Signed: 05/22/2020 05:58:42 PM

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
02/14/2020 and conducted by Evaluator Shobhana Frank

COMPLAINT CONTROL NUMBER: 22-AS-20200214124751

FACILITY NAME:	DJ GUEST HOME		FACILITY NUMBER:	306005335
ADMINISTRATOR:	BANGGALAT, REGIE		FACILITY TYPE:	740
ADDRESS:	2710 N BERKELEY ST		TELEPHONE:	(657) 224-9328
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS: 5	DATE:	05/22/2020
		UNANNOUNCED	TIME BEGAN:	05:22 PM
MET WITH:	Teleconference - Administrator Brevet Doe		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Possible illegal eviction

INVESTIGATION FINDINGS:

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

As precautionary health measures during the current public health crisis, Licensing Program Analyst (LPA) Shobhana Frank conducted a teleconference call with Administrator (AD) Brevet Dao to deliver the findings. LPA explained the purpose of this call; the allegation described in this complaint filed against the facility on 2/19/2020.
During the initial visit on 2/19/2020 LPA toured the facility Administrator, Hospice Nurse, resident’s son and obtained documents related to the allegation. from Superior Hospice care Superior Hospice Care; INC. package dated 2/8/2020. Physician report dated 2/8/2020, Incomplete Admission agreement dated 2/7/2020, Current Treatment Medication list date 2/8/2020, Admission Record from Montebello Care Center dated 10/31/2019.
The investigation into allegation of Possible illegal eviction revealed the following:
LPA Frank reviewed R 1’s physician’s report LIC 602 dated 2/8/2020, report indicates that R1 was diagnosed with late stage of dementia, Anxiety, Agitation, Diabetes, Alzheimer, unable to stand. R 1 is on

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2020

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 3

Control Number 22-AS-20200214124751

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: DJ GUEST HOME	FACILITY NUMBER: 306005335
	VISIT DATE: 05/22/2020

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

special Puree diet and needs Maximum or total assistant. Admission Record from Montebello Care Center dated 10/31/2019 report indicates that R 1 was admitted at Montebello Care Center on 10/31/2019. Based interview of Hospice Nurse R1 was going to be discharged on 2/7/20 from the Montebello Care Center, family had hired Superior Hospice services for R 1 and requested if they can find a RCFE facility for R1. On 2/7/2020 Administrator of DJ Gust Home was contacted by Superior Hospice Care Nurse if DJ Guest Home has vacancy for share room and AD said yes. Hospice Nurse contacted the family and with family’s agreement R 1 was transferred to DJ Guest Home on 2/7/2020 around at 7:00pm. Upon arrival of R 1 administrator had provided a copy of admission agreement for R 1’s admission at DJ Gust Home. Next day on 2/ 8/2020 the Son said that facility’s monthly payment was high for him as he has a lower budget. The family did not sign the admission agreement as planned. On 2/8/2020 Hospice nurse started look for placement. On 2/9/2020 Hospice Nurse was still coordinating to transfer (R 1) to another location with the agreement of the family and will be transferred ASAP. While Hospice Nurse was looking for affordable place for R 1. The facility had continued provided care and supervision and Hospice care to R 1. During the time R 1 become violent, agitated, kicking or hitting the caregivers, going in another residents’ room. Administrator had reported to the hospice nurse that R 1’s behavior has become verse residents and caregivers are afraid of being hurt. Hospice Nurse had discussed the behavior issue with R 1’s son. AS R 1’s behavior was getting verse and she was running fever. R 1 was transported to Norwalk Hospital. Before R 1 transported to the Norwalk Hospital the agreement was made with the Superior Hospice Care and the family that as family doesn’t want to keep R1 at the facility and R1 is not a resident of the facility R 1, will not be returned to the DJ Guest Home. On 2/14/2020 when Norwalk Hospital brought R 1 back to the facility the facility was not informed by Superior Hospice Care that R 1 was returning at the facility. Also, facility’s Land line phone was out of order, if Norwalk Hospital had called, the facility was unable to receive the call. Facility did not open the door as facility was not expecting anyone at nighttime.
Based on the reviews of Incomplete Admission agreement dated 2/7/2020, Interview of Superior Hospice Nurse, Administrator and R 1’s son, the facility has provided Admission Agreement package to the family, but monthly payment was high for the family as they had a lower budget.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20200214124751

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: DJ GUEST HOME	FACILITY NUMBER: 306005335
	VISIT DATE: 05/22/2020

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

R 1 was not DJ Gust Home’s resident. Interviews of Facility administrator, Superior Hospice Care and R 1’s Son reveled that R 1 was not evicted by the facility; however, R 1 was transported to the Norwalk Hospital with agreement not to bring R 1 back to the DJ Guest Home. R 1 reside at DJ Guest Home from 2/7/2020 to 2/12/2020 and facility had provided care and supervision as one of their residents. The payment for six days was not paid by the Superior Hospice Care or R 1’s Son.
This agency has investigated the complaint allegation of Possible illegal eviction determined UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit teleconference was conducted with Administrator Brevet Doe, LPA Frank discussed and read this report. Copy of this report will be provided via email; and AD agreed to confirm the receipt of the document.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3