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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881039
Report Date: 04/11/2025
Date Signed: 04/11/2025 02:08:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
06/26/2023 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230626120054
FACILITY NAME:A & M TEAKWAY HOME CAREFACILITY NUMBER:
361881039
ADMINISTRATOR:ROSA DELA, MONALIZA AFACILITY TYPE:
735
ADDRESS:7979 TEAK WAYTELEPHONE:
(909) 527-3780
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:4CENSUS: 3DATE:
04/11/2025
UNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Facility Staff-Javier GarciaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident sustained unexplained bruising to face and body due to neglect.
Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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First Allegation-Resident sustained unexplained bruising to face and body due to neglect.

Licensing Program Analysts (LPA) Beena Singh conducted an unannounced visit to the facility to deliver findings on a complaint alleging neglect/lack of supervision. LPA Singh met with Facility staff Javier Garcia, facility representative, and was granted entry into the facility. The investigation conducted by Department staff consisted of interviews and records review.

Review of the facility records indicate Resident 1 (R1) would refuse to go to sleep at night. Staff reported R1 required constant supervision during all hours of the day because R1 would refuse to sleep and frequently fell. Records show that R1 fell approximately 10 times while at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
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 4
Control Number 56-AS-20230626120054
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A & M TEAKWAY HOME CARE
FACILITY NUMBER: 361881039
VISIT DATE: 04/11/2025
NARRATIVE
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Six (6) staff members reported it was difficult to care for R1 because R1 would constantly walk around the facility even when R1 was visibly tired, and R1 would not follow instructions when redirected. Staff reported that R1 wore a protective helmet during the day to protect R1’s head. However, no other preventative measures were implemented to deter R1 from falling or injuring self.

In addition, R1’s mother disclosed the facility failed to notify her of the majority of the falls R1 sustained while at the facility. The review of the medical records revealed the hip/thigh injury first observed by staff on June 4, 2023, was not medically evaluated until July 2, 2023 (29 days after) and determined to be an erythema, hard, lump hematoma with no evidence of a fracture. The interview of the attending nurse revealed the injury to R1’s hip should have been immediately evaluated after it was noticed by staff.

Based on the evidence the allegation that resident sustained unexplained bruising to face and body due to neglect is Substantiated. A substantiated finding means that the allegation is valid because the preponderance of the evidence standard has been met.




Second Allegation: Facility failed to seek medical attention in a timely manner.

The evidence indicate staff confirmed R1 required constant supervision during all hours of the day because R1 would refuse to sleep and frequently fall. Facility records revealed staff documented an unexplained “swollen bruise” to R1’s left hip on June 4, 2023, and noted a change in behavior. The morning and afternoon shift noted R1 did not walk and during dinner appeared to be crying. Three (3) staff reported the bruise to the hip should have been medically evaluated. However, the facility failed to notify R1’s mother of the injury and did not seek medical attention until July 2, 2023 (29 days later) at the request of R1’s mother.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20230626120054
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A & M TEAKWAY HOME CARE
FACILITY NUMBER: 361881039
VISIT DATE: 04/11/2025
NARRATIVE
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The interview of R1’s mother revealed she was not notified of any falls and noticed the bruising on R1 during a home visit. The medical records revealed R1 was diagnosed with an erythema, hard, lump hematoma on his left thigh. The interview of the attending nurse revealed the hip injury should have been medical evaluated immediately after it was first notice by staff.

Based on the evidence the allegation that staff failed to seek timely medical attention for R1 is Substantiated. A substantiated finding means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where reports (LIC9099, LIC9099-C & LIC9099-D) were discussed and provided with appeal rights to Facility representative Javier Garcia at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20230626120054
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A & M TEAKWAY HOME CARE
FACILITY NUMBER: 361881039
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2025
Section Cited
CCR
80065(a)
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Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.This requirement is not met at evidenced by:

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Licensee to train all staff on CCR 80065(a) and submit proof of Training Log to LPA Beena Singh by POC due date. Licensee stated to submit signed Statement of Understanding on CCR 80065(a) and submit to LPA Singh by POC due date.
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Based on the evidence, the Licensee failed to provide proper supervision to R1 resulting in R1 sustaining injuries to face and body which pose immediate health, safety, and personal rights risk to residents in care.
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The POC is due by 04/12/2025.
Type A
04/12/2025
Section Cited
CCR
85075.4
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The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any..This requirement is not met at evidenced by:
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Licensee stated to train all staff on CCR 85074.4 and submit proof of Training Log to LPA Beena Singh by POC due date.
Licensee stated to submit signed Statement of Understanding on CCR 85074.4 and submit to LPA Singh by POC due date.
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 facility failed to notify R1’s responsible party of R1’s injuries and did not seek timely medical attention until July 2, 2023 (29 days later) at the request of reporting party.
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The POC is due by 04/12/2025.
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: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4