374600904-10-26-2023-08-AS-SJAB-CX5N2X-20231031100527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600904
Report Date: 10/26/2023
Date Signed: 10/26/2023 08:38:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2023 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20230824151021

FACILITY NAME:	L & M RESIDENTIAL		FACILITY NUMBER:	374600904
ADMINISTRATOR:	LARA, OSCAR		FACILITY TYPE:	735
ADDRESS:	2840 VIA DEL ALLAZON		TELEPHONE:	(619) 267-4955
CITY:	BONITA	STATE: CA	ZIP CODE:	91902
CAPACITY:	4	CENSUS: 3	DATE:	10/26/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Oscar Lara Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff engaging in altercations with resident in care
Staff threatening resident in care
Staff mismanaging residents medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the finding in the above mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Licensee Oscar Lara.

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents and outside sources.

It was alleged that staff engaged in altercations with resident in care. LPA Domingo interviewed Resident 1 (R1) (See LIC811 Confidential Names list) and the resident stated that the staff is respectful and R1 has no complaints regarding staff or the care the staff provide. R1 does not recall any staff altercations with any residents.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230824151021

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: L & M RESIDENTIAL	FACILITY NUMBER: 374600904
	VISIT DATE: 10/26/2023

NARRATIVE

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Continued from LIC9099

LPA Domingo interviewed Resident 2 (R2) was interviewed and R2 stated that there are no concerns regarding the staff and the care the staff provide. R1 does not recall any staff altercations with any residents. Outside Source 1 (OS1) stated that there have been no care complaints regarding this facility. OS1 observed the residents at this facility have been treated with respect and dignity.

It was alleged staff threatening resident in care. LPA Domingo interviewed Resident 1 (R1) and the resident stated that the staff is respectful and R1 has no complaints regarding staff or the care the staff provides. LPA Domingo Interviewed Resident 2 (R2) was interviewed and R2 stated that there are no concerns regarding the staff and the care the staff provide. R2 also stated that the residents all get along well. Outside Source 1 (OS1) stated that there have been no care complaints regarding this facility. OS1 observed the residents at this facility have been treated with respect and dignity.

It was alleged that staff was mismanaging resident medication. LPA Domingo interviewed Staff 1 (S1) and outside source 2 (OS2) unknowingly packed Resident 3 (R3) medication upon discharge. OS2 returned the medication to the adult day care center R3 participated in. All residents at the facility did not miss any doses of medication.

Based on LPA's interviews with Residents, outside source interviews, and records reviewed there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Licensee Oscar Lara, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

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