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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604078
Report Date: 09/14/2021
Date Signed: 09/14/2021 04:34:57 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/21/2020 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20200821103147
FACILITY NAME:MARYAM RCFEFACILITY NUMBER:
374604078
ADMINISTRATOR:DOST, LEEDAFACILITY TYPE:
740
ADDRESS:4930 MAIDEN LANETELEPHONE:
(858) 348-7247
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 5DATE:
09/14/2021
UNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Janet Acosta, CaregiverTIME COMPLETED:
01:48 PM
ALLEGATION(S):
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Staff member records residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes arrived at the facility to deliver findings for a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Janet Acosta, Caregiver. LPA previously conducted interviews, made observations, and obtained and reviewed pertinent records. LPA conducted the initial visit on August 26, 2020, and conducted a tour of the facility. It was alleged that the staff member records residents. Interviews revealed that Staff #1 (S1) did record C1 while at the facility. Interviews revealed it was mentioned to mangement and management asked S1 why they recorded the client. Interviews revealed there was an incident when S1 recorded C1 because they were sitting on the balcony talking about the buildings and S1 asked C1 if anyone had touched their stuff. C1 responded to S1 that another staff went into their room and touched their stuff. Management wrote S1 up for recording C1. Interviews revealed S1 thought that they could show management the recording of C1 so management could see what C1 was saying.

**Amended report from 06/23/2021**
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/21/2020 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20200821103147

FACILITY NAME:MARYAM RCFEFACILITY NUMBER:
374604078
ADMINISTRATOR:DOST, LEEDAFACILITY TYPE:
740
ADDRESS:4930 MAIDEN LANETELEPHONE:
(858) 348-7247
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 5DATE:
09/14/2021
UNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Janet Acosta CaregiverTIME COMPLETED:
01:48 PM
ALLEGATION(S):
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9
Staff member abuses residents
Staff member neglects residents' basic care needs
Staff member fails to treat residents with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes arrived at the facility to deliver findings for a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Janet Acosta Caregiver. LPA previously conducted interviews, made observations, and obtained and reviewed pertinent records. LPA conducted the initial visit on August 26, 2020, and conducted a tour of the facility. It was alleged staff member abuses residents. Interviews did not reveal any physical or emotional abuse to clients by staff. Staff 1 (S1) in question denies abusing any residents. S1 does not speak rudely or mean to the residents. S1 admits to doing the best they can on their job. Interviews revealed staff do not abuse residents.There were no witnesses to prove staff member abuses residents.
Continued...
Amended report from 06/23/2021
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20200821103147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MARYAM RCFE
FACILITY NUMBER: 374604078
VISIT DATE: 09/14/2021
NARRATIVE
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It was alleged staff member neglects residents' basic care needs. Interviews revealed that residents needs are met and anytime they need assistance they receive it. Interviews revealed staff check on residents frequently. Staff provides meals and assistance to the residents several times on a daily basis. The residents receive assistance with bathing and dressing. Interviews with outside sources states the staff provides quality care to the clients in care. Clients needs are met according to their care plans There were no witnesses to prove staff neglects residents basic care needs.

It was alleged that staff member fails to treat residents with dignity and respect. Interviews revealed that staff talk and treat the residents kindly. Interviews revealed staff respect the residents needs and their wants. Interviews revealed there haven't been any instances when staff have been rude or disrespectful at any time. Interviews with clients revealed that staff are nice and clients have a good rapport with them. Interviews with outside sources states that there have been no complaints of staff not treating clients with dignity and respect. There were no witnesses to prove staff member fails to treat residents with dignity and respect.

This agency has investigated the complaint allegations of staff member abuses residents, staff member neglects residents' basic care needs and staff member fails to treat residents with dignity and respect. Based on interviews conducted, the allegations are unsubstantiated.

An exit interview was conducted with Janet Acosta, Caregiver, and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided to Licensee, Leeda Dost via email. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20200821103147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MARYAM RCFE
FACILITY NUMBER: 374604078
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidenced by:
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Licensee will provide training on personal rights of clients to all staff from Medicine Camp Pharmacy. Documents/materials and sign in sheet will be provided to CCL by POC date of 09/24/2021
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Interviews revealed 1 out of 4 clients were being recorded while in care at the facility by staff.
This poses a potential safety risk to clients in care,
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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: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 08-AS-20200821103147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MARYAM RCFE
FACILITY NUMBER: 374604078
VISIT DATE: 09/14/2021
NARRATIVE
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Interviews revealed that staff are not supposed to use their phones when working with the residents. There were witnesses to prove staff records residents.

Based on interviews conducted, the allegation is substantiated. This agency has investigated the complaint alleging staff member records residents. We have found the allegation happened and the preponderance of evidence has been met.

An exit interview was conducted with Janet Acosta, Caregiver and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided to Licensee, Leeda Dost via email. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5