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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603358
Report Date: 07/16/2024
Date Signed: 07/16/2024 05:41:09 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
07/10/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240710130340
FACILITY NAME:SUPERCARE GUEST HOMEFACILITY NUMBER:
198603358
ADMINISTRATOR:JABONERO, JANICE RACHELLEFACILITY TYPE:
740
ADDRESS:13449 BIOLA AVETELEPHONE:
(714) 244-5885
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 4DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Christian CJ Catacutan, CaregiverTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner.
Staff did not properly assess resident before acceptance.
Staff did not assist resident in a timely manner.
Staff did not accommodate residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegations listed above. LPA arrived unannounced and met with Staff, CJ Catacutan. The purpose of the visit was explained. The licensee, Ruby Cruz, arrived shortly thereafter to assist.

The investigation consisted of the following:
LPA obtained a copy of the staff roster, resident roster, and documents for Resident #1 (R-1). Interviews were held with the licensee, administrator, 2 staff, 3 residents, Director of Case Management of the West Anaheim Medical Center, and the Director of the Legacy Home Health. Resident #1 was also interviewed via telephone.

The investigation revealed the following:
For allegation - Staff did not seek medical attention for resident in a timely manner. It is alleged that staff did not seek medical attention for Resident #1 after a fall. LPA interviewed facility staff and they were not aware
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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-20240710130340
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: 07/16/2024
NARRATIVE
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that R-1 had a fall. They stated that R-1 never reported a fall and would seek medical attention right away if residents fell. Staff stated they contacted 911 on 7/1/24 due to R-1 having a fever and the oxygen level was low. LPA interviewed R-1, who stated that resident was experiencing pain on the foot and had a fever, so staff called for emergency services right away. R-1 did not state it was a fall.

For allegation - Staff did not properly assess resident before acceptance. It is alleged that the administrator accepted Resident #1 who has a bedsore on the buttock and a blister on the foot. LPA interviewed the licensee, administrator, facility staff, and directors to obtain information on R-1. The administrator stated that a pre-appraisal was completed for R-1 to determine if resident was appropriate for the home. Upon admission, a body check was also performed and had indicated where they observed any skin conditions. LPA reviewed the body check form which noted the areas in which the resident had a scratch (buttock) and a blister on foot. Per the staff, R-1 was receiving wound care from home health in those areas. LPA interviewed the Director of Care Management who indicated the health conditions of R-1 was fully disclosed to the administrator prior to acceptance and is aware not to recommend anyone who has a stage 3 or 4 wound to an assisted living facility. The Director of the Home Health agency also stated that R-1 was being treated for a diabetic wound which is not stageable as it is not considered a pressure wound.

For allegation - Staff did not assist resident in a timely manner. It is alleged that staff do not assist resident #1 to the bathroom when requested. Administrator and staff stated they check on the residents often and provide assistance when they need it. Staff stated they respond to residents right away when they call for them. LPA interviewed R-1 who stated staff assisted him/her to the restroom and has nothing bad to say about the care provided. The other 3 residents interviewed stated staff tend to them when they need something.

For allegation - Staff did not accommodate residents. It is alleged that the facility ramps are not convenient for residents. LPA toured the facility today and observed a total of 3 ramps located in the front, back, and inside the house. It was designed to help residents in wheelchairs or walkers to navigate around the home. LPA did not observe any obstructions to the ramps or walkways. The ramps appeared wide enough to fit wheelchairs. Staff and residents do not have any concerns regarding the accommodations.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
An exit interview was conducted. A copy of this report along with the appeal rights were provided to the staff.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
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