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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606656
Report Date: 07/21/2021
Date Signed: 07/21/2021 02:27:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2021 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20210714152940
FACILITY NAME:KATIE'S HOUSEFACILITY NUMBER:
197606656
ADMINISTRATOR:CARRIE DOBRENENFACILITY TYPE:
740
ADDRESS:15459 GARO STREETTELEPHONE:
(626) 336-8273
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:6CENSUS: 5DATE:
07/21/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Carrie Dobrenen-AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff speak inappropriately to residents
Facility staff did not assist residents with hygiene needs
Facility staff did not assist residents with making doctor appointment
Facility staff do not ensure that residents have an adequate amount of clothing
Facility staff are not ensuring that there is an adequate amount of food in the facility
Facility is not clean
Facility staff restrained resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christine Wong and Alberto Lopez conducted a complaint visit to investigate the above allegations; LPAs met with staff Andrew Baez and explained the reason for the visit. Shortly after, the house manager Nick Baez and Administraor Carrie Dobrenen arrived the facility and assisted with the visit.

The investigation consisted of the following: LPAs interviewed five (5) residents (R1- R5). LPAs also interviewed five staff (S1-S5) and reviewed all residents' file and toured the facility.

The investigation revelaed of the following: Allegation#1 "Facility staff speak inappropriately to residents" LPA interviewed all residents and all reported staff never speak inappropriately or yelled at them. All the staff are nice. LPA interviewed staff and all denied the allegation. The staff stated they would never do that to residents and they never observed any staff speak inappropriately to residents
(See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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 6
Control Number 28-AS-20210714152940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KATIE'S HOUSE
FACILITY NUMBER: 197606656
VISIT DATE: 07/21/2021
NARRATIVE
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Allegation#2 "Facility staff did not assist residents with hygiene needs" LPA interviewed 5 residents and they stated that they assisted them with showering and all other hygiene needs. All staff take good care of them. LPAs also observed the resident dress appropriate with clean and nice clothes , hair got brushed, no bad odor and all nails got trimmed. All residents in the facility are able to maintain cleanliness and good hygiene.

Allegation#3 "Facility staff did not assist residents with making doctor appointment" LPA interviewed residents and the staff are always on top of it. LPA interviewed staff and they reported residents usually sees their doctor regularly. Staff also stated that if something emergency and they will send resident to urgent care or emergency room immediately. LPA also reviewed residents' file and they all have an updated physician report. They all had a lab test between February and April, 2021. They also had monthly visit with psychiatrist through video chat. In addition, all residents also had a recent dental appointment on May, 2021.

Allegation#4 " Facility staff do not ensure that residents have an adequate amount of clothing. LPA interviewed all residents and they reported that they all have enough clothes. LPAs also observed all five residents closet and they all have sufficient amount of clothing which included different weather clothing. Staff also reported they will assist residents with shopping during this pandemic.

Allegation#5 "Facility staff are not ensuring that there is an adequate amount of food in the facility." LPA interviewed all residents and all reported that they do have well enough amount of food for each meal. Staff also denied the allegation and reported they always provide variety of food option to resident. They would provide substitute choice if resident does not like the food on the menu. LPA also toured the kitchen, and observed the refrigerator and storage for food supply and they have the supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.

Allegation#6 "Facility is not clean." LPA interviewed resident and reported the facility is always clean. LPAs toured the facility and observed the facility is clean, with no smell and all the appliances looks working and functioning properly.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2021 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20210714152940

FACILITY NAME:KATIE'S HOUSEFACILITY NUMBER:
197606656
ADMINISTRATOR:CARRIE DOBRENENFACILITY TYPE:
740
ADDRESS:15459 GARO STREETTELEPHONE:
(626) 336-8273
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:6CENSUS: 5DATE:
07/21/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Nick Baze - House Manger TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff are not following resident's dietary restrictions
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christine Wong and Alberto Lopez conducted a complaint visit to investigate the above allegations; LPA met with staff Andrew Baez and explained the reason for the visit. Shortly after, the house manager Nick Baez arrived the facility and assisted with the visit.

The investigation consisted of the following: LPA interviewed five (5) residents (R1- R5). LPA also interviewed five staff (S1-S5) and reviewed all residents' file and toured the facility.

The investigation revelaed of the following: Allegation "Facility staff are not following resident's dietary restrictions" LPA toured the facility kitchen refrigerator and observed there are a lot of frozen food for resident which included frozen lasagna, chicken nuggets..etc. LPA also observed the lunch that were served to resident which include two pieces of bologna, two pieces of wheat bread, string cheese and shadded carrot.
(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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 6
Control Number 28-AS-20210714152940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KATIE'S HOUSE
FACILITY NUMBER: 197606656
VISIT DATE: 07/21/2021
NARRATIVE
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While LPA observed residents' nursing recommendation and recommended R1 with special diet which include low fat diet, NAS (No Added Salt) due to high cholosterol, R2 with low sodium, healthy and 1800 calories diet. R3 with low sodium, 1800 calories diet due to hypertension. R4 with low sodium , healthy and 1800 calories diet due to hypertension. On today's lunch, the bologna contains a lot of sodium and fat as well as some preservatives.

Based on the record review and LPA's observation, therefore, the allegation is substantiated. The following deficiency was cited per California Code of Regulations, Title 22. Refer to 9099D.

Exit interview conducted. A copy of the report and appeal rights were discussed and provided to the House Manager Nick Baze
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20210714152940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KATIE'S HOUSE
FACILITY NUMBER: 197606656
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2021
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements (a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents
The requirement is not met as evidenced by
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Facility/Licensee will provide an updated special meal plan for R1 and other residents with low sodium diet meal plan for residents and send to LPA by POC due date.
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Based on the record review and LPAs observation, LPA observed today's lunch with bologna sandwiches with shadded carrot and string cheese but R1-R4 are recommended to have low sodium diet, healthy diet and 1800 calorie and speical diet for R1 due to their medical codnition which pose a potential risck to resident 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.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20210714152940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KATIE'S HOUSE
FACILITY NUMBER: 197606656
VISIT DATE: 07/21/2021
NARRATIVE
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Allegation#7 "Facility staff restrained resident." LPA interviewed residents and all denied staff restrained them. LPA interviewed staff and denied the allegation and reported they never tired resident with blanket while the resident on the wheelchair. LPA reviewed R5's file and observed R5's doctor recently prescribed the gait belt and used around the wheelchair for safety issues but staff stated that they are only planning to use the gait belt for transporting in an out from the car to the doctor appointment. Staff did not restrain resident.

Based on the interviews were conducted and LPA's observation, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and the copy of the report and appeal right was provided to Administrator-Carrie Dorbrenen.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6