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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880598
Report Date: 12/19/2022
Date Signed: 12/19/2022 11:30:23 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2022 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221213101559
FACILITY NAME:A AND M KELLY HOME CAREFACILITY NUMBER:
361880598
ADMINISTRATOR:LADY ROXANNE ARCIBALFACILITY TYPE:
735
ADDRESS:1474 KELLY AVETELEPHONE:
(909) 618-7065
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:4CENSUS: 4DATE:
12/19/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mona DeLARosa and Roxanne ArcibalTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff is not ensuring resident's medical needs are being met.
Resident has gained a significant amount of weight.
Staff leaves resident in diaper.
Staff does not provide resident with proper sized clothing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above-mentioned allegations. LPA Prieto met with administrator Roxanne Arcibal and licensee Mona Delarosa and discussed the elements of the complaint. Staff interviews and documentation will reveal the client #1 (C1) is having medical needs being met with monthly visits with a Primary Physician for Health Check ups and Behavioral Consults. Hospitalization records were obtained and are related to C1s diagnosis. C1 also has a direct consultant who addressed weight gain related to medication and behaviors, which are addressed regular at quarterly meetings. Documentation and consultant interviews, suggest C1 health and behaviors are stable. C1 does leave the facility with personal supply of incontinence items which are appropriate in size for C1's weight and height. Observations and interviews will show that C1 has various sizes of clothing to meeting any personal changes in size or proportions.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
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 56-AS-20221213101559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: A AND M KELLY HOME CARE
FACILITY NUMBER: 361880598
VISIT DATE: 12/19/2022
NARRATIVE
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Based on the information obtained there is not enough evidence that staff is not ensuring resident's medical needs are being met, resident has gained a significant amount of weight, staff leaves resident in diaper, s taff does not provide resident with proper sized clothing. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2