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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603585
Report Date: 01/10/2025
Date Signed: 01/10/2025 12:15:45 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
01/03/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250103101146
FACILITY NAME:HENRIETTA'S HOMEFACILITY NUMBER:
198603585
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:131 SEGOVIA AVENUETELEPHONE:
(626) 703-4958
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:6CENSUS: 5DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Belen Taico, House ManagerTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff did not provide safe and competent assistance with postural support of terminally ill resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit Lead Caregiver Andres Hernandez. House Manager Belen Taico arrived shortly after.

The investigation consisted of: A physical plant tour of the facility and record review was completed. Staff (S1-S4) were interviewed. No residents were interviewed due to cognitive impairment. Resident (R1) passed away and was not interviewed. The following documents were reviewed/obtained: Resident (R1's) Face Sheet, Death Report, Preplacement Appraisal, Resident Appraisal, Valley Hospice Orders, Physician's Report, Plan of Operation, resident roster, and LIC 500 Personnel Report.


Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
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 5
Control Number 28-AS-20250103101146
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: HENRIETTA'S HOME
FACILITY NUMBER: 198603585
VISIT DATE: 01/10/2025
NARRATIVE
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Allegation: Staff did not provide safe and competent assistance with postural support of terminally ill resident. It is alleged that on June 3, 2024 at 6:09 AM Dementia resident (R1) was found laying in the hospital bed in an unusual manner. The lower part of the bed foot area was propped higher with a laundry basket. According to report night shift staff (S1) was on duty and is suspected to be the caregiver staff who placed the basket in order to prevent the hospice resident from getting up often during nighttime. According to information obtained, the incident was reported to House Manager, but no action was taken to ensure resident's safety. The resident was receiving hospice services and passed away August 11, 2024. A total of 4 staff were interviewed, of which all denied the allegation. Three (3) staff saw the 3 pictures obtained by Community Care Licensing and acknowledged staff negligence. The staff in question staff (S1) denied the allegation, and stated that a former staff (S5) was likely the caregiver that placed the laundry basket under R1's mattress. House Manager stated that former staff (S5) complained that R1's was difficult to care for and often got up at night. Manager stated that S5 said that pillows and bed rail pads were used to concave R1 in the bed in order to keep the resident in bed. House Manager stated there was disciplinary action against former staff (S5), but the caregiver refused to sign the document. There is sufficient evidence to corroborate the allegation.

Based on interviews conducted, record review, and photographic evidence the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited in LIC 9099D.

An exit interview was conducted and a copy of this report and appeal rights was provided to House Manager Belen Taico.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250103101146
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: HENRIETTA'S HOME
FACILITY NUMBER: 198603585
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/11/2025
Section Cited
CCR
87608(a)(5)
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Postural Supports. Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.”
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Administrator shall submit a written plan of correction by tommorrow.

Submit staff in-service training by Tue. Jan. 14, 2025.
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Based on photographic evidence night shift caregiver placed a laundry basket under R1's hospital bed mattress in order to limit the resident from getting up at night. Pillows and rail pads were also used. This poses an immediate health and safety 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: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/03/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250103101146

FACILITY NAME:HENRIETTA'S HOMEFACILITY NUMBER:
198603585
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:131 SEGOVIA AVENUETELEPHONE:
(626) 703-4958
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:6CENSUS: 5DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Belen Taico, House ManagerTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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3
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9
Staff are interfering with daily functions by putting residents to bed early
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit Lead Caregiver Andres Hernandez. House Manager Belen Taico arrived shortly after.

The investigation consisted of: A physical plant tour of the facility and record review was completed. Staff (S1-S4) were interviewed. No residents were interviewed due to cognitive impairment. Resident (R1) passed away and was not interviewed. The following documents were reviewed/obtained: Resident (R1's) Face Sheet, Death Report, Preplacement Appraisal, Resident Appraisal, Valley Hospice Orders, Physician's Report, Plan of Operation, resident roster, and LIC 500 Personnel Report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250103101146
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: HENRIETTA'S HOME
FACILITY NUMBER: 198603585
VISIT DATE: 01/10/2025
NARRATIVE
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Allegation: Staff are interfering with daily functions by putting residents to bed early. It is alleged that caregiver staff are putting to bed residents too early, at approximately 5:30 PM after dinner time because only one (1) caregiver staff works the night shift staff. According to information obtained, staff are doing this in order to facilitate the night shift caregiver responsibilities. Day shift begins at 7 AM and ends at 7 PM. The night shift staff work from 7 PM - 7 AM. The complaint alleges day shift staff are instructed to get the resident ready for bed after they eat dinner and before the night shift staff begins their shift. Based on interviews conducted a total of 2 caregivers work the day shift. A total of 4 staff were interviewed. One (1) out of the 4 staff stated the residents are taken to their rooms at approximately 6 PM, before the night shift staff starts their shift. Other staff stated that if the residents are placed in bed early it is out of choice. House Manager stated that former resident (R1) liked to go to bed early because they awakened early. Per Plan of Operation, residents are supposed to be prepared for bed at 8:00 PM, and residents may go to sleep at 9:00 PM, or earlier if desired. Due to Dementia diagnosis residents are cognitively impaired and were not interviewed. There is insufficient 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 conducted with House Manager Belen Taico. A copy of the report was issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5