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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601959
Report Date: 01/21/2025
Date Signed: 01/21/2025 12:46:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/13/2025 and conducted by Evaluator Bennette Pena
COMPLAINT CONTROL NUMBER: 28-AS-20250113161518
FACILITY NAME:MOM & DAD'S HOUSEFACILITY NUMBER:
198601959
ADMINISTRATOR:IVONNE A. MEADERFACILITY TYPE:
740
ADDRESS:4340 CONQUISTA AVE.TELEPHONE:
(562) 627-0390
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY:6CENSUS: 6DATE:
01/21/2025
UNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Jose Umana - Acting AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial 10-day visit to investigate the above allegation. LPA met with Editha Padua/Caregiver and April SIlva/Cargiver and explained the purpose of the visit. Administrator Ivonne Meader is out of town but LPA spoke to her on the phone at 10:50am and explained the reason for the visit. At 12noon, Jose Umana, acting Administrator arrived and assisted LPA with the investigation.

The investigation cosisted of the following: LPA Pena obtained copies of the staff & resident rosters, Staff In service training certificates (Recognizing and Reporting Abuse, Resident's Rights, Dementia related Behaviors), Resident #1 (R1) files such as: Identification and Emergency Information, Resident Appraisal, Admission Agreement, Physician's report, Hospital Discharge record, Medication Record (Oct 2024) and Unusual Incident/Injury Report (12/16/2024). LPA interviewed Staff #1 (S1) telephonically, Staff #2 (S2) - Staff #3 (S3) in person and Resident #2 (R2) - Resident #3 (R3). LPA attempted to interview Resident #4 (R4) - Resident #6 (R6), but unsuccessful due to their cognitive abilities. Resident #1 (R1) is out in a specialized hospital; therefore not interviewed. ******CONTINUED ON LIC 9099C*****
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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-20250113161518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOM & DAD'S HOUSE
FACILITY NUMBER: 198601959
VISIT DATE: 01/21/2025
NARRATIVE
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The investigation revealed the following:

In regards to the allegation: "Staff handled resident in a rough manner." It is alleged that a staff pushed and shoved R1 on a daily basis. Specific details of the alleged incident were not provided. Interview conducted with (3) of (3) staff members all denied the allegation. Staff members interviewed indicated that they have never pushed nor shoved any resident nor have they observed any other staff member push/shove any of the residents. Staff interviewed also stated that they treat all residents with respect and they received zero tolerance policy, elderly abuse and mandated reporting training yearly. S1 stated that R1 was admitted to a specialized hospital approx. 2 months ago due to exhibiting behaviors of mental health concern such as confusion, anxiousness, medication refusal and food refusal. (2) out of (5) residents interviewed also denied the allegation. Interviewed residents indicated that facility staff treat them with dignity and they feel safe at the facility. Residents interviewed also indicated they have never observed staff members push or shove any of the residents. Therefore there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation.



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.

Exit interview and a copy of this report was provided to the Acting Administrator, Jose Umana.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2