198603358-10-3-2023-28-AS-DSIS-CWGK62-20231010073646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603358
Report Date: 10/03/2023
Date Signed: 10/03/2023 02:59:29 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
07/29/2021 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210729111636

FACILITY NAME:	SUPERCARE GUEST HOME		FACILITY NUMBER:	198603358
ADMINISTRATOR:	JABONERO, JANICE RACHELLE		FACILITY TYPE:	740
ADDRESS:	13449 BIOLA AVE		TELEPHONE:	(714) 244-5885
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY:	6	CENSUS: 6	DATE:	10/03/2023
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Jen Jimenez - Caregiver		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident sustained unexplained fall resulting in severe injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Jen Jimenez (Caregiver) and explained the purpose of the visit.

Investigation consisted of the following:
During the initial unannounced 10-day complaint visit conducted on 08/03/21, LPA Joe Katrdzhyan reviewed the file of Resident #1 (R1) and obtained copies of the following documents of R1 medical records along with other supporting documentation pertaining to the allegation.

This Investigation was investigated by Investigator Spindola with the Investigations Branch and revealed the following:
In regards to the allegation “Resident sustained unexplained fall resulting in severe injuries” it is alleged that Resident #1 (R1) had an unwitnessed fall at the care home and resident suffered severe injuries as a result of the fall. (Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210729111636

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: SUPERCARE GUEST HOME	FACILITY NUMBER: 198603358
	VISIT DATE: 10/03/2023

NARRATIVE

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Interviews conducted with facility staff, residents, and R1's family revealed that R1 had a medical condition that would cause R1 to try to ambulate on their own without asking for assistance from facility staff resulting in accidental falls. Interview with Staff #1 (S1) revealed that R1 would have delusional behaviors and although not present during R1s fall the fall was said to be the cause of R1 lowering bedrail and ambulating unassisted. Staff interviewed denied any wrongdoing. Review of medical records confirmed diagnosis of medical conditions that resulted in delusional behavior and psychosis episodes, which would cause R1 to try to ambulate without assistance. R1 was admitted to the facility on 7/13/2021, was hospitalized on 7/28/21 after R1 sustained a fall from trying to ambulate unassisted, and passed in the hospital on 8/21/21.
During Investigator Spindola's investigation there was no supportive evidence that revealed facility staff neglected R1 and the injuries that R1 sustained were most likely due to the medical condition and trying to ambulate without assistance.

Based on statements and interviews conducted with staff, clients, family, review of facility file records and medical records, there was not enough supportive evidence to concur with the reported 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 held and a copy of this report was provided to Jen Jimenez.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC9099 (FAS) - (06/04)

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