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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881041
Report Date: 11/13/2024
Date Signed: 11/13/2024 04:24:59 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2024 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240308082752
FACILITY NAME:GRACIOUS LIVINGFACILITY NUMBER:
361881041
ADMINISTRATOR:KAO, ANGELFACILITY TYPE:
740
ADDRESS:2141 N EUCLID AVETELEPHONE:
(626) 622-0671
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: 5DATE:
11/13/2024
UNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Leofel Capulong, House ManagerTIME COMPLETED:
04:24 PM
ALLEGATION(S):
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Facility did not provide resident's records to resident's authorized representative.
Facility did not ensure that resident's had a TB test
Facility recommended hospice services for resident
Facility has cameras in common areas that is being monitored
Facility is not providing cable
INVESTIGATION FINDINGS:
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Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Leofel Capulong and explained the purpose of the visit.

On March 8, 2024, Community Care Licensing received a complaint alleging facility did not provide resident's records to resident's authorized representative, facility does not provide well balanced meals, facility did not ensure that residents had a TB test, facility has cameras in common areas that are being monitored, and facility is not providing cable. LPA conducted interviews with Administrator, staff, residents, and additional witnesses. LPA also conducted a review of pertinent documentation. LPA was unable to interview Resident #1 (R1) in order to obtain pertinent information due to R1 passing away on March 17, 2024.

(Continued on Page 2)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
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 3
Control Number 56-AS-20240308082752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GRACIOUS LIVING
FACILITY NUMBER: 361881041
VISIT DATE: 11/13/2024
NARRATIVE
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(Continued on from Page 1)

In regards to the allegation that facility did not provide resident’s records to resident’s authorized representative, it was reported that on March 7, 2024, R1’s authorized representative provided a handwritten request to obtain R1’s records and staff refused. Interview with resident’s authorized representative stated that records were received March 9, 2024. Information obtained by Administrator stated that records were sent on June 4, 2024. LPA conducted a review of pertinent documentation that corroborated the request for records, records sent and received.

Regarding the allegation facility did not ensure that residents had a Tuberculosis (TB) test, it was reported that R1’s TB test was read on May 4, 2023, by R1’s primary doctor; however, the visitor log did not include a sign-in visit from the primary doctor. Information obtained from Administrator, staff, and residents, indicated that a TB test is required prior to being placed at the facility. It was advised that R1 had their TB test conducted on May 2, 2023, and read on May 4, 2023. LPA reviewed pertinent documents in resident’s files that included documentation of a TB test for all clients in care prior to placement. Interview with additional witness indicated that TB test was done on May 13, 2022 and read on May 16, 2022 and another TB test was done on March 1, 2024 and read on March 4, 2024.

In regards to the allegation facility recommended hospice services for resident, it was reported that Licensee and Administrator pushed for R1 to be placed on hospice. Information obtained from R1’s representative indicated that R1 was not on hospice when R1 moved into the facility on May 17, 2022. LPA conducted interviews with Administrator, staff and residents. Information obtained stated that R1’s start of care for hospice was on April 28, 2022. LPA conducted a review of R1’s hospice documents indicated that R1 was on hospice prior to moving into the facility.

It was also alleged that the facility has cameras in common areas that are being monitored by Administrator. Information obtained from Administrator, staff, and residents, stated that cameras are in the common area and are being monitored. It was further advised that the cameras do not record audio which is in accordance to the reference material provided by the department. Cameras were observed by the LPA in the common areas only. LPA reviewed the facility’s plan of operation/program statement in which cameras are not part of the program.
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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20240308082752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GRACIOUS LIVING
FACILITY NUMBER: 361881041
VISIT DATE: 11/13/2024
NARRATIVE
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(Continued from Page 2)

Regarding the allegation facility is not providing cable, it was reported that the cable in the living room was turned off, prohibiting residents from being able to watch. Information obtained from Administrator, staff, residents and witness indicate that residents are provided streaming services in each of their room and the living room. LPA observed the living room television and resident’s room with streaming channels. Review of the facility’s plan of operation, program statement, and or placement agreement indicates that cable is available in the living room of the facility, Residents can pay an extra charge to have it available in their bedrooms.

Based on staff interviews, resident interviews, facility records, the allegations facility did not provide resident’s records to resident’s authorized representative, facility did not ensure that residents had a TB test, facility recommended hospice services for resident, facility has cameras in common areas that is being monitored, facility is not providing cable, we have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided along with LIC811- Confidential Names list.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3