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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880912
Report Date: 10/23/2023
Date Signed: 10/23/2023 12:56:46 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230427101245
FACILITY NAME:A & A CARE AND WELLNESSFACILITY NUMBER:
361880912
ADMINISTRATOR:AKOPYAN, HELENFACILITY TYPE:
740
ADDRESS:16055 SEQUOIA STREETTELEPHONE:
(818) 588-2894
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 2DATE:
10/23/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Tyeshia Jones, caregiverTIME COMPLETED:
01:01 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is being over medicated.
Residents were left alone in the facility.
The facility is requiring a client to hide when guests come to the facility.
The staff are not properly logging medications in the medical record (MAR).
The staff is not able to communicate with the residents based on a language barrier.
The staff is not following resident’s special diet.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegations. LPA met with caregiver Tyeshia Jones, and explained the purpose of the visit. The investigation included a file reviews and interviews with relevant parties.

Allegation #1: “Resident is being over medicated.” The allegation alleged that the Licensee requires their staff to administer pro re nata (PRN) medication to resident #1 (R1) when the PRN is not required. LPA Nickolas, with staff #1 (S1) and staff #2 (S2), revealed that they denied this allegation. LPA Nickolas’ interview with R1 revealed that they could not participate in the interview process. LPA Nickolas' interview with resident #2 (R2) revealed that they denied this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #2” Residents were left alone in the facility”. The allegation alleged that the licensee left residents alone in the facility without supervision.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
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 56-AS-20230427101245
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: A & A CARE AND WELLNESS
FACILITY NUMBER: 361880912
VISIT DATE: 10/23/2023
NARRATIVE
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8
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LPA Nickolas' interview with the licensee revealed that they denied this allegation. LPA Nickolas' interview with S1 and S2 revealed that they denied this allegation. LPA Nickolas' interview with R1 revealed that they could not participate in the interview process. LPA Nickolas' interview with R2 revealed that they could not provide any information about this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #3 “The facility is requiring a client to hide when guests come to the facility”. The allegation alleged that the licensee had instructed staff to hide resident #3 (R3) when visitors came to the facility. LPA Nickolas' interview with the licensee revealed that they denied this allegation. LPA Nickolas' interview with S1 and S2 revealed that they denied this allegation. LPA Nickolas' interview with R2 revealed they could not provide information about this allegation. LPA Nickolas' interview with R1 revealed that they could not participate in the interview process. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #4 “The staff are not properly logging medications in the medical record (MAR)”. The allegation alleged that the staff was not trained to dispense medication. Therefore, the owner completes the medication administration record (MAR) later. LPA Nickolas's interview with the licensee revealed that they denied this allegation. LPA Nickolas' interview with S1 and S2 revealed that they denied this allegation. On May 1, 2023, a medication audit was conducted by LPA Nickolas' during the initial complaint visit. LPA Nickolas' medication audit of all residents in care revealed no discrepancies. LPA Nickolas's medication audit also revealed that the medication administration records. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #5 “The staff is not able to communicate with the residents based on a language barrier”. The allegation alleged that a facility staff member could not communicate with residents in care because of a language barrier. LPA Nickolas’ interview with the licensee revealed that they denied this allegation. LPA Nickolas’ interview with S1 and S2 revealed that they denied this allegation. LPA Nickolas’ interview with R2 revealed that they denied this allegation. LPA Nickolas' interview with R1 revealed that they could not participate in the interview process. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230427101245
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: A & A CARE AND WELLNESS
FACILITY NUMBER: 361880912
VISIT DATE: 10/23/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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21
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24
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32
Allegation #6 “The staff is not following resident’s special diet”. The allegation alleged that R2 has a special diet that the facility is not adhering to. LPA Nickolas’ interview with the licensee revealed that they denied this allegation. LPA Nickolas interview with S1 and S2 revealed that they denied this allegation. LPA Nickolas' file review confirmed that R2 has special diet. However, there is no evidence that the facility staff is not adhering to R2's special diet.The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3