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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005501
Report Date: 02/15/2023
Date Signed: 02/15/2023 12:24:54 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220113153608
FACILITY NAME:JEWEL HOMECARE 1FACILITY NUMBER:
306005501
ADMINISTRATOR:PAO, WESLEYFACILITY TYPE:
740
ADDRESS:5111 HAMER LNTELEPHONE:
(424) 270-4452
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 6DATE:
02/15/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Manager Rowel RiveraTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident claims facility staff are poking his eye and slapping his hand off the table
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Michelle Reed arrived at the facility to complete this complaint investigation. Upon arrival, LPA met with Manager Rowel Rivera. Administrator Wesley Pao was contacted and he stated he could not come to the facility. Three residents were resting in their rooms and three were watching tv in the living room.

Resident #1 was admitted into the facility on 9/2/20. Resident #1 has Parkinson, Mild Cognitive Impairment and is wheelchair bound. He needs assistance with all activities of daily living. Interviews with random staff disclosed that R1 can get very confused and agitated at times. Staff deny personal rights violations. Residents present could not be interviewed due to their cognitive impairment.

Based upon the review of records and the interviews conducted with staff, R1 and witnesses, the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Rowel Rivera and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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