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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 04:47:31 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,
, 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:
04:35 PM
MET WITH:Leofel Capulong, House ManagerTIME COMPLETED:
04:47 PM
ALLEGATION(S):
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Facility failed to report a resident went to the hospital
INVESTIGATION FINDINGS:
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Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced at the facility to conclude an investigation for the above allegation. LPA Delgado met with Leofel Capulong and explained the purpose of the visit.

On March 8, 2024, Community Care Licensing received a complaint alleging that facility failed to report a resident went to the hospital. It was reported that a resident was choking and ended up at the hospital about a month ago. LPA conducted interviews with Administrator, staff, 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.

It was alleged that on January 29, 2024, Resident #2 (R2) was choking at the facility and was transported to the hospital. Information obtained from Administrator indicated that R2 was being visited by family
(Continued on Page 2)
Substantiated
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 from Page 1)

member when R2 began choking on a small piece of cantaloupe. It was advised that Staff #1 (S1) performed Heimlich maneuver and Staff #2 (S2) contacted emergency personnel services. Emergency personal arrived and transported R1 to the local hospital. Administrator indicated that the facility did send a serious incident report to Community Care Licensing (CCL). Administrator provided a serious incident report of an incident that occurred on January 29, 2024, involving R2. LPA requested confirmation of the incident being reported to CCL. Administrator provided an email sent to another LPA on March 13, 2024. Administrator was unable to provide proof of the incident report being sent abiding by Title 22 regulations. LPA was unable to locate any information pertaining to an incident on January 29, 2024, or pertaining to R2 in the Regional Office internal database.

Title 22 Regulations, Section 87211 (1) indicates that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified. Therefore, based on observations and interviews, the allegation that facility failed to report a resident went to the hospital is SUBSTANTIATED. The facility will be cited for Title 22, Division 6, Chapter 8, Article 04, Section 87211 (1)(D). This poses a health and safety and or personal rights risk to clients in care.

An exit interview was conducted where this report, 9099-D, and appeal rights were discussed. Copies of the documents were provided to House Manager.
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2024
Section Cited
CCR
87211(1)(D)
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87211 Reporting Requirements : (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Licensee will report any incidents involving residents within the time frame as required, document and maintain records of confirmation of incidents sent to CCLD. Licensee will review regulation and conduct training and submit copy by email to LPA by POC due date.
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(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not being met as evidenced by: Facility did not report to CCLD that 911 was called for R2 and was taken to the hospital. This poses a potential health and safety risk.
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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: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

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

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
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