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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603538
Report Date: 03/07/2024
Date Signed: 03/07/2024 02:07:13 PM

Substantiated


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
02/27/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240227160538
FACILITY NAME:ALL IN CAREHOMEFACILITY NUMBER:
198603538
ADMINISTRATOR:YAMASHIRO, SHELLYFACILITY TYPE:
740
ADDRESS:1158 BEAVER WAYTELEPHONE:
(626) 698-9615
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:6CENSUS: 5DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator Shelly YamashiroTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not ensure that a hazardous item was made inaccessible to resident.
Staff did not maintain the facility in clean and sanitary condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 03/07/2024 regarding the above allegations. LPA Ramirez was met by Caregivers Rosalyne Obedoza and Edwin Uy and explained the purpose of the visit. Administrator Shelly Yamashiro arrived shortly after to assist with tour.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident Roster (LIC 9020), Staff Roster (LIC 500), Staff#1 - 3 interviews(S1 – S3), copy of Staff#2-3 (S2-S3) Personnel Record (LIC 501), Attempted interview of Resident#1-6 (R1-R6), Resident# 1-6 (R1- R6) review of resident records, copies of Resident#1-5 Physician’s Report, and physical plant tour.

SEE 9099-C for continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 5
Control Number 28-AS-20240227160538
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: ALL IN CAREHOME
FACILITY NUMBER: 198603538
VISIT DATE: 03/07/2024
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Staff did not ensure that a hazardous item was made inaccessible to resident- It is alleged staff allow hazardous items to become accessible to residents in care. Three (3) out of the three (3) staff interviewed deny this allegation. At 8:52 am, LPA Ramirez toured shred bathroom #1. LPA Ramirez observed a can of Ajax powder bleach cleaner, sitting on top of bathroom cabinet. At 9:10 am. LPA Ramirez toured private bathroom#2 located in resident bedroom#3. LPA Ramirez observed a spray bottle of Clorox Bleach Germicidal Cleaner in bathroom shower. Four (4) out of five (5) residents in the home suffer from cognitive impairments. LPA Ramirez will issue deficiency based on observations. Based on observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

Staff did not maintain the facility in clean and sanitary condition- It is alleged the facility has mold in a bathroom and is dirty. Three (3) out of the three (3) staff interviewed deny this allegation. During tour of private bathroom#2 located in bedroom#3, LPA Ramirez observed blackish spots/and grime around the corner of the bathroom window, behind toilet and near toilet wall, and in between some of the tiles of the shower. LPA Ramirez will issue deficiency based on observations. Based on observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

Deficiencies are being cited today. A copy of this report, 9099-D and appeals rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240227160538
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: ALL IN CAREHOME
FACILITY NUMBER: 198603538
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2024
Section Cited
CCR
87705(f)(2)
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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

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Staff removed cleaning products and placed in secure location. **This will clear 24hr POC** Licensee will retrain staff on above regulation by 3/21/24. Proof of re-training must be sent by 3/21/24.
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(2)Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement was not met as evidence by:
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LPA Ramirez observed cleaning products to be accessible to residents in care during visit.
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240227160538
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: ALL IN CAREHOME
FACILITY NUMBER: 198603538
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee will clean area and send picture proof to LPA by 03/21/2024.
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This requirement was not met as evidence by:
LPA Ramirez observed blaskish spots and stains in bathroom#3 shower, near toilet wall and around window frame.
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5