331880906-8-18-2023-18-AS-EMAN-CUWMPP-20230821094726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880906
Report Date: 08/18/2023
Date Signed: 08/18/2023 12:30:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2021 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211130121753

FACILITY NAME:	A & J RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	331880906
ADMINISTRATOR:	YOUNES, AMIRRA		FACILITY TYPE:	735
ADDRESS:	1229 KELLEY AVE		TELEPHONE:	(650) 656-7941
CITY:	CORONA	STATE: CA	ZIP CODE:	92882
CAPACITY:	6	CENSUS: 4	DATE:	08/18/2023
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Jennifer Culadilla- Caregiver		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Staff are not ensuring client is getting dental care.
Staff are not providing adequate assistance with client's oral hygiene.
Client's room does not have adequate storage for client's clothing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to investigate and issue findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Caregiver Jennifer Culadilla. The investigation consisted of client interviews, staff interviews, tour of the client’s bedrooms, and document review.

For allegation, Staff are not ensuring client is getting dental care:

Interviews with clients, interviews with the staff, and document review revealed that that three (3) of the four (4) clients at the facility are contracted through the InnovAge Pace Program. The InnovAge Pace Program sets up the client’s dental care and provides transportation to the dental appointments. The one (1) client that is not contracted with the InnovAge Pace Program has dental visits that are scheduled and transported by the facility administrator. Interviews with the client’s revealed there are not any issues with receiving proper dental care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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 18-AS-20211130121753

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A & J RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 331880906
	VISIT DATE: 08/18/2023

NARRATIVE

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For allegation, Staff are not providing adequate assistance with client's oral hygiene:

Interviews with the clients, interviews with the staff, and document review revealed that the client’s take care of their own oral hygiene needs. Document review of the client’s physician’s reports detailed that three (3) out of the four (4) clients are self-responsible for their grooming needs. Review of the client’s physician’s reports detailed that one (1) client needs assistance with grooming. Interview with the one (1) client and the staff revealed that the only assistance the client needs is occasional reminders from the staff and the actual grooming is completed on their own. Interviews with the clients revealed there are not any issues with adequate oral hygiene assistance.

For allegation, Client's room does not have adequate storage for client's clothing:

Interviews with the client’s revealed that the client’s have adequate storage space for their clothing items. LPA tour of the client’s bedrooms revealed that the clients have closet space, as well as portable two (2) drawer chests in each bedroom to store their clothing items.

Overall, there was not enough evidence to collaborate the allegations listed above.

Based on evidence obtained during the investigation, the three (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means 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.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Caregiver Jennifer Culadilla, along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC9099 (FAS) - (06/04)

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