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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603604
Report Date: 08/29/2023
Date Signed: 08/29/2023 12:45:33 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
08/21/2023 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230821113645
FACILITY NAME:A BELOVED HOME OF DIAMOND BARFACILITY NUMBER:
198603604
ADMINISTRATOR:DUONG, MY MYFACILITY TYPE:
740
ADDRESS:454 S ROCK RIVER RDTELEPHONE:
(626) 899-6999
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 3DATE:
08/29/2023
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Genia Polistico/S-1 and Elizah Arganosa (Administrator Assistant/S-3).TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Residents are not provided proper medication assistance.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Genia Polistico/S-1 and explained the purpose for the visit. Elizah Arganosa (Administrator Assistant/S-3) arrived at approximately 9:45 A.M..

During this investigation, LPA obtained a copy of the resident and staff rosters, a copy of the menu and diet restrictions, reviewed files, medication and Medication Administrator Records (MARs) for Resident #1 through Resident #3 (R-1 through R-3) and obtained relevant documentation, conducted a facility tour, interviewed Staff #1 through Staff #3 (S-1 through S-3) and interviewed Resident #1(R-1) and Resident #3 (R-3). LPA was unable to interview R-2 as R-2 was resting at the time of this visit.

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: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
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 6
Control Number 28-AS-20230821113645
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: A BELOVED HOME OF DIAMOND BAR
FACILITY NUMBER: 198603604
VISIT DATE: 08/29/2023
NARRATIVE
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Allegation: Residents are not provided proper medication assistance. It is alleged that staff are making medication errors. LPA reviewed resident medications and the Medication Administration Records (MAR). It was discovered that (R-3) had the following over-the-counter medications without a physician’s order: Tussin DM Max, Stool Softener and Stimulant Laxative (Docusate Sodium 50mg Sennosides 8.6mg), Anti-Diarrheal (Loperamide HCI Tablets-2mg) and Antacid Maximum Strength. Per staff interviews, the medications listed above have been provided to R-3 as followed: Tussin DM Max was last administered on 08/23/23. Stool Softener and Stimulant Laxative (Docusate Sodium 50mg Sennosides 8.6mg) has been administered daily. Anti-Diarrheal (Loperamide HCI Tablets-2mg) was last administered 08/05/23. Antacid Maximum Strength last administered on 08/26/23. Medication review and staff interviews corroborates this allegation.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED.

Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC9099-D.

An exit interview was conducted, a copy of appeal rights and this report was provided to Elizah Arganosa (Administrator Assistant/S-3).
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20230821113645
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: A BELOVED HOME OF DIAMOND BAR
FACILITY NUMBER: 198603604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2023
Section Cited
CCR
87465(e)
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Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label of the medication
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Administrator to obtain a physician’s order for the medication referenced on this citation.

Administrator to submit a written statement as to how staff will adhere to this regulation and provide it to LPA Irra by POC due date
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This standard is not met as evidence by: R-3 had the following medications without a physician’s order: Tussin DM Max, Stool Softener and Stimulant Laxative (Docusate Sodium 50mg Sennosides 8.6mg), Anti-Diarrheal (Loperamide HCI Tablets-2mg) and Antacid Maximum Strength.
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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: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
08/21/2023 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230821113645

FACILITY NAME:A BELOVED HOME OF DIAMOND BARFACILITY NUMBER:
198603604
ADMINISTRATOR:DUONG, MY MYFACILITY TYPE:
740
ADDRESS:454 S ROCK RIVER RDTELEPHONE:
(626) 899-6999
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 3DATE:
08/29/2023
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Genia Polistico/S-1 and Elizah Arganosa (Administrator Assistant/S-3).TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Residents in care have access to centrally stored medications.
Staff do not ensure facility is kept clean.
Staff do not provide proper incontinence care to residents in care.
Staff are unable to communicate with residents in care.
Residents are not provided proper food service.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Genia Polistico/S-1 and explained the purpose for the visit. Elizah Arganosa (Administrator Assistant/S-3) arrived at approximately 9:45 A.M..

During this investigation, LPA obtained a copy of the resident and staff rosters, a copy of the menu and diet restrictions, reviewed files, medication and Medication Administrator Records (MARs) for Resident #1 through Resident #3 (R-1 through R-3) and obtained relevant documentation, conducted a facility tour, interviewed Staff #1 through Staff #3 (S-1 through S-3) and interviewed Resident #1(R-1) and Resident #3 (R-3). LPA was unable to interview R-2 as R-2 was resting at the time of this visit.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
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 6
Control Number 28-AS-20230821113645
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: A BELOVED HOME OF DIAMOND BAR
FACILITY NUMBER: 198603604
VISIT DATE: 08/29/2023
NARRATIVE
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Allegation: Residents in care have access to centrally stored medications. It is alleged that resident's creams and ointments are being left accessible to residents. During the facility tour, LPA did not observe any medications being left accessible to residents. Per staff interviews, medications are centrally stored and locked inside the hallway cabinet. LPA observed the medications to be locked and inaccessible to residents. Staff indicated they have not received any complaints/concerns in regards to this matter. Per resident interviews, staff administer medication to residents. Per resident interviews, there are no medications kept inside their bedrooms. Interviews do not corroborate this allegation.

Allegation: Staff do not ensure facility is kept clean. It is alleged that the facility is unclean and staff do not clean resident rooms regularly. During the facility tour, LPA observed this facility to be clean and well organized. Per staff interviews, this facility is cleaned and kept clean daily. Per staff interviews, the facility is deep cleaned (3) times per week. Additionally, staff indicated they dust, sweep, mop and take out the trash daily. Per staff interviews, they have not received any complaints/concerns in regards to the facility not being kept clean. Per resident interviews, staff clean this facility on a daily basis (including their bedrooms). Per resident interviews, they do not have any concerns regarding this matter. Interviews do not corroborate this allegation.

Allegation: Staff do not provide proper incontinence care to residents in care. It is alleged that residents diapers are not being changed timely and cleaned correctly. Per staff interviews, staff provide proper incontinence care to residents in care in a timely manner and residents are cleaned correctly. Per staff interviews, staff conduct rounds frequently and attend to resident needs. Per staff interviews, all residents also have a call button to use when they need staff assistance. Staff indicated they have not received any complaints/concerns in regards to this matter. Per resident interviews, staff provide incontinence care to residents in a timely manner and staff clean residents correctly. Per resident interviews, they do not have any concerns regarding this matter. During the facility tour, LPA observed additional incontinence supplies for R-1 through R-3 stored inside the attached garage. Interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20230821113645
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: A BELOVED HOME OF DIAMOND BAR
FACILITY NUMBER: 198603604
VISIT DATE: 08/29/2023
NARRATIVE
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Allegation: Staff are unable to communicate with residents in care. It is alleged that residents are having trouble with speaking to care staff due to a language barrier and not understanding English well, causing issues to arise. Per staff interviews, staff are able to effectively communicate with residents. Interviewed staff indicated they have not received any complaints/concerns in regards to communication. Interviewed residents indicated that staff are able to communicate with residents. Interviewed residents indicated they do not have any concerns in regards to this matter. Interviews do not corroborate this allegation.

Allegation: Residents are not provided proper food service. It is alleged that the facility is not serving residents healthy meals. During the facility tour, LPA observed sufficient amount of food supply. There was a variety of nutritious foods available such as fresh fruits, vegetables, meats, eggs, milk ect.. LPA obtained a copy of the facility menu and resident's dietary restrictions. Both, the food menu and dietary restriction lists were observed to be posted on the refrigerator doors. Interviewed staff indicated the facility provides proper food service. Interviewed staff indicated they follow the menu and the residents’ dietary restrictions. Staff indicated residents receive (3) meals and snacks in between meals. Staff indicated they have not received any complaints/concerns regarding this matter. Resident interviews revealed that staff provide proper food service. Per resident interviews, staff provide (3) meals and snacks in between. Interviewed residents indicated they enjoy the food that is provided and do not have a concerns. Interviews do not corroborate this allegation.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove
the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED.

Per California Code of Regulations, Title 22, no deficiencies were observed or cited.

An exit interview was conducted, a copy of appeal rights and this report was provided to Elizah Arganosa (Administrator Assistant/S-3).
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6