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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320046
Report Date: 04/22/2022
Date Signed: 05/19/2022 09:00:00 AM

Unfounded


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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2022 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220418162850
FACILITY NAME:DROCK HOME CAREFACILITY NUMBER:
198320046
ADMINISTRATOR:ADAMSON RUKAYATFACILITY TYPE:
740
ADDRESS:1652 E CYRENE DRIVETELEPHONE:
(310) 997-8046
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:6CENSUS: 6DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Rukayat AdamsonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are harassing residents authorized representative regarding payment
INVESTIGATION FINDINGS:
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***This report serves as an amendment to report created on 4/22/2022 . This report supersedes the complaint investigation findings reflected on report created 4/22/2022.***
On 4/22/2022 at 1:25pm, Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegation listed above. LPA was allowed entry into the facility by Administrator Rukayat Adamson. LPA explained to Ms. Adamson the purpose of the visit. The investigation consisted of the following: On 4/22/2022, LPA and Administrator conducted an inspection of the facilities’ physical plant, LPA conducted an interview with Administrator; and LPA was provided the following documents: LIC 500-Staff Roster; Client Roster; R1’s Admission Agreement; and R1’s Physician Report. The investigation revealed the following: Regarding the allegation: “Staff are harassing residents authorized representative regarding payment.” On 4/22/2022 interviews conducted by LPA indicates that the complaint allegation did not involve R1 but involved a third party LPA was informed by Administrator that on 4/13/22, she sent a text message to R1’s POA, informing that an outstanding rent payment was due. ” We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.An exit interview was conducted with Rukayat Adamson, Administrator and a hard copy of a LIC 9099 and LIC 9099D was provided.


Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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 2
Control Number 11-AS-20220418162850
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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DROCK HOME CARE
FACILITY NUMBER: 198320046
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
HSC
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This LIC 809D report serves as an amendment to report created on 4/22/2022 . This report supersedes the LIC 809D report created on 4/22/2022. Complaint findings Unfouned, No deficiences cited.
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2