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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366408657
Report Date: 07/22/2022
Date Signed: 07/22/2022 02:41:52 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
07/15/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220715090758
FACILITY NAME:RODELLA HOME CAREFACILITY NUMBER:
366408657
ADMINISTRATOR:AGPALO, NORMA AREVALOFACILITY TYPE:
740
ADDRESS:17446 MADRONE STTELEPHONE:
(909) 574-6832
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:6CENSUS: 3DATE:
07/22/2022
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Max Zapanta, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff hit resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on this allegation. LPA met with Max Zapanta, administrator. The investigation consisted of file review, interviews with relevant parties, and observations of the facility.

Interviews revealed that Resident 1 (R1) reported being hit by Staff 1 (S1). Staff interviews revealed that R1 has aggressive tendencies and needed redirection while receiving assistance to prevent injuries. Interviews further reveal that S1 hit R1's hand while being assisted in the toilet.

Based on LPA's interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
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 4
Control Number 56-AS-20220715090758
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: RODELLA HOME CARE
FACILITY NUMBER: 366408657
VISIT DATE: 07/22/2022
NARRATIVE
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California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC-9099D. Refer to LIC-9099D for deficiency cited.

An exit interview was conducted where this report, LIC-9099D, and Appeal Rights were discussed and provided to Administrator Zapanta.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/15/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220715090758

FACILITY NAME:RODELLA HOME CAREFACILITY NUMBER:
366408657
ADMINISTRATOR:AGPALO, NORMA AREVALOFACILITY TYPE:
740
ADDRESS:17446 MADRONE STTELEPHONE:
(909) 574-6832
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:6CENSUS: 3DATE:
07/22/2022
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Max Zapanta, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Medication not administered as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on this allegation. LPA met with Max Zapanta, administrator. The investigation consisted of file review, interviews with relevant parties, and observations of the facility.

Interviews revealed that residents medications are ordered by the physician and staff pick up the medication at the local pharmacy. LPA observed that the facility keeps track of the medication through the centrally stored medication log and track medication intake by marking the medication packs.

This allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with and a copy of this report was provided to Mr. Zapanta.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20220715090758
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: RODELLA HOME CARE
FACILITY NUMBER: 366408657
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in All Facilities: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Licensee shall submit to the Department a Memoranding of Understanding of Personal Rights of Residents in All Facilities as outlined in Section 87468.1. Licensee shall submit proof of correction be end of POC date.
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This requirement was not met as evidenced by:

Based on interviews, Staff 1 hit Resident 1 while receiving assistance. This is poses a potential risk of personal rights violation for both residents, 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.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4