306005932-4-28-2022-22-AS-LADS-CFTLBX-20220628083729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005932
Report Date: 04/28/2022
Date Signed: 04/28/2022 08:37:17 PM

Unfounded

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
04/25/2022 and conducted by Evaluator Lydia Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220425120258

FACILITY NAME:	A MOTHER THERESA CARE		FACILITY NUMBER:	306005932
ADMINISTRATOR:	PAO, WESLEY		FACILITY TYPE:	740
ADDRESS:	16192 CAIRO CIRCLE		TELEPHONE:	(714) 792-0967
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 6	DATE:	04/28/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Wesley Pao		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility illegally evicted resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced 10-day visit to initiate the investigation into the allegation listed above. LPA Martinez was greeted and granted entry into the facility by Maruja Camilon and reason for the visit was explained. Administrator (AD) Wesley Pao arrived shortly after.
LPA toured the facility, interviewed Resident 1 (R1), reviewed R1's file, medication list and medications. The investigation revealed the following: R1 was admitted into the facility on 4/19/2022. At the time of admission, R1 arrived with no medication and the wrong size equipment had been delivered the morning of 4/19/2022. Review of active medication list from Los Alamitos Medical Center dated 4/19/2022 shows R1 is on 23 types of medication, (3 types of insulin) and 3 types of inhalation treatment medication that require a Nebulizer to administer. R1 confirmed that when R1 arrived to the facility R1 had no medication, no glucometer, lancets, syringes and/or testing strips and no Nebulizer for her breathing treatment. After several attempts to have R1's prescription filled, R1 was sent to Placentia-Linda Hospital on 4/20/2022 for having no medication. R1 was discharged on 4/21/2022 with instructions to pick up medications at the local pharmacy since issue with medication had been fixed. (see LIC9099C)

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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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Control Number 22-AS-20220425120258

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A MOTHER THERESA CARE	FACILITY NUMBER: 306005932
	VISIT DATE: 04/28/2022

NARRATIVE

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AD stated that not all medication was ready, but was given 2 types of insulin pens with no needles and no glucometer, lancets, or testing strips. R1 was contacting Durable Medical Equipment company to obtain the Nebulizer but had been unsuccessful. R1 was sent back to Placentia-Linda Hospital on 4/21/2022 due not having all medication and Nebulizer for breathing treatment.

AD reported that on 4/22/2022, around 3:00pm, he received a call from hospital staff stating R1 was ready to be discharged. AD stated he could not meet R1's needs due to not having all of R1's medication, glucose test kit and Nebulizer. Per AD, it took several attempts to get some of R1's medication from the Pharmacy. This is re-iterated by R1. R1 told LPA, R1 was not ready to be discharged from the hospital on Friday 4/22/2022. R1 was discharged from the hospital with a glucometer, lancets, syringes and testing strips on 4/25/2022.

During today's visit, R1 was transported to the Emergency Room due to R1 having shortness of breath. R1 needed a breathing treatment but did not have the Nebulizer.

Based on interviews and information obtained during the investigation the allegation is Unfounded meaning the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint and no deficiencies are being cited. An exit interview was conducted and copy of this report will be emailed.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

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