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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602633
Report Date: 10/31/2022
Date Signed: 10/31/2022 12:53:13 PM

Substantiated


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
10/26/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221026164421
FACILITY NAME:GIANA'S HOME #1FACILITY NUMBER:
198602633
ADMINISTRATOR:FRANCIS MEJIAFACILITY TYPE:
740
ADDRESS:4263 LA JUNTA DRIVETELEPHONE:
(909) 534-0132
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 5DATE:
10/31/2022
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Brian Tria, CaregiverTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility is not following Covid-19 safety protocols
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegation.The purpose of the visit was discussed with staff Artemio Trio. Licensee/Administrator was explained the purpose of the visit telephonically.

The investigation consisted of: A tour of the interior and exterior physical plant was conducted. Staff (S1-S4) were interviewed. Resident (R1) was interviewed; the other 4 residents are cognitively impaired and were not interviewed. LPA obtained a copy of the COVID-19 Mitigation Plan. Licensee has not completed or submitted a an Infection Control Plan (ICP) that was due June 30, 2022. A Technical Advisory was issued. A copy of PIN 22-28-ASC and LA County Department of Public Health mask guidelines were issued today.

NOTE: Licensee made alterations to the garage. A separate case management report was issued.

See LIC 9099C for report continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
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 3
Control Number 28-AS-20221026164421
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: GIANA'S HOME #1
FACILITY NUMBER: 198602633
VISIT DATE: 10/31/2022
NARRATIVE
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Allegation: Facility is not following Covid-19 safety protocols. It is alleged that on September 30, 2022, a visitor observed staff (S1) not wearing face masks, and put a mask on 5 minutes after the visitor entered the facility. Staff (S1) was interviewed and stated it does not remember the incident. Staff (S1) is a live-in staff, and stated that most of the time it wears a mask when working its shift. Administrator/Licensee stated staff are instructed to conduct temperature checks and staff and visitors are required to wear a mask, but it allows staff not to wear a mask if they are not providing direct care to residents, or when they are "far enough" from residents. Administrator stated that all three (3) live-in staff are not required to wear a mask when they are inside their living quarters. Staff (S3 & S4) stated they do not wear a mask when they are in inside the staff rooms. Staff interviews revealed the LA County Department of Public Health mask guidelines are not being followed as required. Per current Los Angeles County Department of Public Health guidelines all staff and visitors must wear masks while working "In congregate care facilities, such as long-term care settings and adult/senior care facilities.

Based on interviews conducted and information obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited. See LIC 9099D.

Exit interview was conducted with Caregiver staff Brian Tria. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20221026164421
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: GIANA'S HOME #1
FACILITY NUMBER: 198602633
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2022
Section Cited
CCR
87470(c)(1)(F)
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Infection Control Requirements. An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. The Infection Control Plan shall include all of the following: Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.
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Licensee/Administrator shall review CCL PINS and LA County Dep of Public Health guidelines and conduct staff training by tomorrow.

Submit proof of staff training.
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This requirement was not met evidenced by:
Based on interviews conducted on 9/30/2022 a visitor observed staff (S1) not wearing a mask, and put a mask on 5 minutes after the visitor entered the facility; which poses an immediate health, safety or personal rights risk to persons 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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3