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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880818
Report Date: 05/16/2024
Date Signed: 05/16/2024 05:13:26 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2020 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200825133437
FACILITY NAME:DIVINE MANOR CARE INCFACILITY NUMBER:
361880818
ADMINISTRATOR:YADAV, SHREETAFACILITY TYPE:
740
ADDRESS:6367 MARBLE AVETELEPHONE:
(347) 449-2449
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY:6CENSUS: 6DATE:
05/16/2024
UNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Raymond Munsayac, CaregiverTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff failed to provide residents proper supervision resulting in excessive falls and serious injuries
Facility staff are not adequately trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Raymond Munsayac, Caregiver and explained the purpose of the visit. During the course of the investigation, records were reviewed, and interviews were conducted with facility staff members and residents.

On August 25, 2020, Community Care Licensing received a complaint alleging facility staff failed to provide residents proper supervision resulting in excessive falls resulting and serious injuries and facility staff are not adequately trained.

Regarding the allegation that “facility staff failed to provide residents proper supervision resulting in excessive falls and serious injuries”, facility records revealed that facility reported falls for Residents #2 and #3 to licensing and facility staff provided first aid, notified Hospice Agency for R2, called 911 for medical attention for R3. Interviews with staff denied that facility staff failed to provide proper supervision resulting in excessive falls and serious injuries, interviews with R3 could not corroborate allegation and R2 is not able to be interviewed.
.
Regarding allegation that “facility staff are not adequately trained”, facility records revealed that that facility staff had been trained on providing care, supervision, medication management. Interviews with staff denied that facility staff are not adequately trained. Interviews with R3 could not corroborate allegation and R1,R2 is not able to be interviewed.

Therefore, the allegations of facility staff failed to provide residents proper supervision resulting in excessive falls and serious injuries and facility staff are not adequately trained is Unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted with Raymond Munsayac and a copy of this report along with LIC811- Confidential Names list was provided.








Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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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