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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801279
Report Date: 05/25/2021
Date Signed: 05/25/2021 03:07:51 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
03/09/2020 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200309151208
FACILITY NAME:LEANING PINE, THEFACILITY NUMBER:
197801279
ADMINISTRATOR:VILLAFLOR, ELNA C.FACILITY TYPE:
740
ADDRESS:1809 LEANING PINE DRIVETELEPHONE:
(909) 396-4675
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 5DATE:
05/25/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Zenaida Uy (Assistant Administrator)TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained a fracture and multiple injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long delivered complaint findings for the above allegations. Upon arrival at the facility, LPA met with Zenaida Uy and explained the purpose of the visit.

During a site visit conducted on 03/11/20, LPA toured the physical plant with Zenaida Uy and observed that the physical plant is in good repair, sufficient food supply, running water, comfortable temperature and adequate staffing was observed. LPA did not observe any immediate Health & Safety risks to resident in care.

The investigation consisted of interviews with Resident #1's family member, facility Administrator, facility Staff and Witness.

Continue to LIC9099C......
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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 2
Control Number 28-AS-20200309151208
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: LEANING PINE, THE
FACILITY NUMBER: 197801279
VISIT DATE: 05/25/2021
NARRATIVE
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Regarding the allegation: Resident sustained a fracture and multiple injuries while in care. The Investigation revealed: Residents #1 family member reported Resident #1 had fallen while residing at another licensed facility prior to being admitted to the facility on 03/01/21. At the time of the fall at the other licensed facility, Resident #1's family member made the decision to not to send Resident #1 to the hospital for evaluation. On 03/01/2020, Resident #1's family member moved Resident #1 into the facility. Interviews with Resident #1's family member, Facility Administrator, Facility Staff and review of facility documents; MD visit communication sheets and progress notes all revealed that on date of admission to the facility (03/01/21), staff observed Resident #1 to have resolving bruises to Rt. forehead, neck, and head. On 03/06/2020, Facility caregivers reported Resident #1 fell out of bed and staff called 911. Resident #1 was transported to a local hospital and diagnosed with multiple new rib fractures, multiple contusions in different healing stages, abrasions of multiple sites, etc. Interviews with hospital staff regarding resident #1 medical condition, revealed that the rib fractures were older than expected and were a few days to a few weeks old. It was also noted by Hospital staff that Resident #1 was diagnosed with Osteoporosis, meaning Resident #1's bones were week and Resident #1 could easily break a bone due to this medical condition and Resident #1 was taking aspirin as a blood thinner, therefore, Resident #1 had greater susceptibility to bruising. In conclusion, it remains unknown if Resident #1 injuries/contusions occurred at the Resident #1 prior facility or her current facility.

Based on the department's record review and interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Zenaida Uy and a hard copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2