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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880912
Report Date: 10/23/2023
Date Signed: 10/23/2023 12:55:37 PM

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
11/22/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221122161723
FACILITY NAME:A & A CARE AND WELLNESSFACILITY NUMBER:
361880912
ADMINISTRATOR:AKOPYAN, HELENFACILITY TYPE:
740
ADDRESS:16055 SEQUOIA STREETTELEPHONE:
(818) 588-2894
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 2DATE:
10/23/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Tyeshia Jones, caregiverTIME COMPLETED:
01:01 PM
ALLEGATION(S):
1
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9
R1's medication not given according to the physician's directions.
Reporting Requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegations. LPA met with caregiver Tyeshia Jones, and explained the purpose of the visit. The investigation included a file reviews and interviews with relevant parties.

Allegation #1 "R1's medication not given according to the physician's directions". The allegation alleged that the facility failed to administer resident #1's (R1's) medication as prescribed by R1's physician. LPA Nickolas' interview with the Licensee revealed that the Licensee confirmed that R1 missed doses of their medication, but it was not the facility's fault. The Licensee stated that there was an issue with the physician's office sending the medication to the pharmacist. LPA Nickolas's interview with staff #1 (S1) revealed that they deny this allegation. LPA Nickolas' interview with staff #2 (S2) revealed that R1's medical insurance carrier would not approve the prescribed medication, so the facility could not refill it. LPA Nickolas interview with R1 revealed that they could not patricipate in the interview process. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
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-20221122161723
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 & A CARE AND WELLNESS
FACILITY NUMBER: 361880912
VISIT DATE: 10/23/2023
NARRATIVE
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Allegation #2 "Reporting Requirements". The allegation alleged that the facility failed to report resident #1’s (R1’s) medication errors. LPA Nickolas’ interview with the Licensee revealed that the Licensee stated they sent a fax about the medication error to the Community Care Licensing Division (CCLD) via fax. The Licensee stated they also reported this incident to another agency. LPA Nickolas’ file review revealed no record of this incident reported to our agency. However, the Licensee has a history of reporting unusual injuries/incidents at the facility before and after this incident. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means 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.

An exit interview was conducted and copy of this report was provided.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2