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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880720
Report Date: 10/17/2022
Date Signed: 10/17/2022 04:34:57 PM

Substantiated


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
03/17/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220317155642
FACILITY NAME:SHAMROCK CARE HOMEFACILITY NUMBER:
361880720
ADMINISTRATOR:DAVALOS, RHEAFACILITY TYPE:
735
ADDRESS:1741 ERIN AVETELEPHONE:
(909) 697-9843
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: 3DATE:
10/17/2022
UNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Almario Quizon, DSPTIME COMPLETED:
04:36 PM
ALLEGATION(S):
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9
Facility has scabies.
Facility did not report scabies outbreak as required.
Resident was allowed to leave the facility unsupervised.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA met with DSP Almario Quizon and Rose Alimurung. The investigation consisted of review of documents, interviews with relevant parties, and observations of facility.

Allegations 1 AND 2: Facility has scabies AND Facility did not report scabies outbreak as required. LPA reviewed 3/11/2022 after care visit for Client 1 (C1) that confirms their scabies diagnosis. Staff interviews revealed that the facility had a scabies outbreak in December 2021. Documents reviewed show that three of four clients had prescription medication from December 2021 for treatment of scabies. LPA did not find any Scabies related incident reports submitted to the Department in December 2021 however an incident report was received on 3/17/22, on the same day that this complaint was received. These allegations are therefore substantiated.

Allegation 3: Resident was allowed to leave the facility unsupervised. Witness and staff interviews corroborated this allegation. Records reviewed reveiled that, while AWOL, is a not usual behavior, C1 requires close
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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 6
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
03/17/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220317155642

FACILITY NAME:SHAMROCK CARE HOMEFACILITY NUMBER:
361880720
ADMINISTRATOR:DAVALOS, RHEAFACILITY TYPE:
735
ADDRESS:1741 ERIN AVETELEPHONE:
(909) 697-9843
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: DATE:
10/17/2022
UNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Almario Quizon, DSPTIME COMPLETED:
04:36 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff sleep while clients are in care.
Staff failed to seek medical attention in a timely manner.
Staff are not meeting clients' hygiene needs.
Facility staff refused to provide laundry services to resident.
Clients' laundry needs are not being met.
Facility washing machine is broken.
Client was kicked by staff while in care.
INVESTIGATION FINDINGS:
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5
6
7
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10
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13
Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA met with DSP Almario Quizon and Rose Alimurung. The investigation consisted of review of documents, interviews with relevant parties, and observations of facility.

Allegation 1: Staff sleep while clients are in care. Interviews with witnesses did not reveal that staff were observed sleeping. Client interview deny that staff sleep while supervising clients in care. LPA did not observe any staff asleep in any area of the facility during multiple LPA visits. This complaint is therefore unsubstantiated.
Allegation 2: Staff failed to seek medical attention in a timely manner. Records reviewed show that clients by their medical provider, specifically for their skin condition. Records reviewed show that all clients were prescribed the same medication during the same time when their skin condition was diagnosed. Records also show clients recent medical appointments. This allegation is unsubstantiated.
Allegation 3: Staff are not meeting clients' hygiene needs. Interviews with staff reveal that clients are receiving their showers timely. LPA observed clients appearing clean and tidy during multiple visits. Client and witness
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 56-AS-20220317155642
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: SHAMROCK CARE HOME
FACILITY NUMBER: 361880720
VISIT DATE: 10/17/2022
NARRATIVE
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interviews reveal that staff are attending to clients’ hygiene needs. This allegation is therefore unsubstantiated.
Allegations 4, 5, and 6: Facility staff refused to provide laundry services to resident. Clients' laundry needs are not being met. Facility washing machine is broken. Witness and staff interviews confirmed that the washing machine was broken and serviced within a few days. Staff interviews revealed that the facility had other means to ensure that the clients' clothing were washed. LPA observed that the facility has ample fresh linens and towels. These allegations are unsubstantiated.
Allegation 7: Client was kicked by staff while in care. Client and staff interviews deny that staff kicked client. Interviews with staff revealed that staff do not kick or physically hurt clients and no staff has witnessed another kick or physically hurt any client. This complaint is unsubstantiated.

A finding of UNSUBSTANTIATED means that although the allegations may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed with and a copy provided to Mr. Quizon.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 56-AS-20220317155642
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: SHAMROCK CARE HOME
FACILITY NUMBER: 361880720
VISIT DATE: 10/17/2022
NARRATIVE
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supervision. Interviews with witness and staff reveal that C1 AWOL and was not easily located, indicating that there was no supervision at the time C1 left the facility. This allegation is substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Refer to LIC809-D for deficiencies cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Mr. Quizon.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20220317155642
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: SHAMROCK CARE HOME
FACILITY NUMBER: 361880720
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2022
Section Cited
CCR
85075.4(d)
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Observation of the Client
A client suspected of having a contagious or infectious disease shall be isolated and a physician contacted to determine suitability of the client's retention in the facility.
This requirement was not met as evidenced by:
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Licensee will have training on observation of clients and documentation. Training date must be submitted to LPA by POC date.
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Witness interviews reveal that clients were not in isolation even after C1 was diagnosed with the skin condition. This poses a potential health and safety issue to clients in care.
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Type B
10/31/2022
Section Cited
CCR
80061(b)(1)(H)
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Upon occurrence, during operation of the facility, of any of the events...below, a report shall be made to Licensing w/in the next working day during normal business hours...A written report containing the information specified below shall be submitted to Licensing agency w/in 7 days following the occurrence of such event. Epidemic outbreaks.
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Licensee will have training on reporting requirements as outlined in CCR section 80061. Incident report training date must be submitted to LPA by POC date.
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This requirement was not met as evidenced by:
CCL did not receive a report on a Scabies outbreak from December 2021. This poses a potential health and safety issue to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20220317155642
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: SHAMROCK CARE HOME
FACILITY NUMBER: 361880720
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2022
Section Cited
CCR
85078(a)(1)
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7
In addition to Section 80078, the following shall apply:
(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
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Licensee shall train administrator and staff to review quarterly current consumer IPP and behaviorist recommendations. Training date must be submitted to LPA by POC date.
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This requirement was not met as evidenced by:
Interviews reveal that client eloped from the facility and staff did not have the location of the client. This poses an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6