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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603590
Report Date: 12/21/2023
Date Signed: 12/21/2023 12:49:15 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
12/18/2023 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231218142407
FACILITY NAME:ALL FOR MOMS HOMECAREFACILITY NUMBER:
198603590
ADMINISTRATOR:TRUONG, PHUOCFACILITY TYPE:
740
ADDRESS:16136 E CLOVERMEAD ST.TELEPHONE:
(626) 456-1066
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 6DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Henry BautistaTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not provide records to resident's authorized person
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial visit to investigate the above allegation. LPA was allowed entry by Henry Bautista. LPA spoke to Phuoc "Henry" Truong (Administrator) via telephone and discussed the purpose of today's visit.

During this investigation, LPA obtained a copy of the resident and staff rosters and interviewed Phuoc "Henry" Truong (Administrator) via telephone.

Allegation: Staff did not provide records to resident's authorized person. It is alleged that multiple requests for R-1's records have been sent to this facility and that R-1's records have not been provided. Per Administrator's interview, Administrator recalls receiving a request "a long time ago" for R-1's records and that R-1's hospice records were the only documents provided. Per Administrator's interview, no other records have been provided. Administrator interview corrborates this allegation. **Refer to LIC 9099C for the continuation of this report**.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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-20231218142407
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 FOR MOMS HOMECARE
FACILITY NUMBER: 198603590
VISIT DATE: 12/21/2023
NARRATIVE
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Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22, Division 6 Health and Safety Code, Chapter 3.2 Residential Care Facilities for the Elderly Article 02.5 Resident's Bill of Rights. Refer to LIC 9099D.

An exit interview was held. A copy of this report along with appeal rights were provided to Henry Bautista.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20231218142407
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 FOR MOMS HOMECARE
FACILITY NUMBER: 198603590
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
CCR
87506(c)(1)
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Resident Records. (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make
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Administrator to provide R-1's records to the authorized/designated representative and provide proof of delivery to LPA Irra by POC due date.


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available confidential information only upon the resident's written consent or that of his designated representative. This standard is not met as evidence by: Per Administrator, hospice records for R-1 were the only documents provided to R-1's representative.
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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: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3