191600500-11-8-2022-11-AS-MVAO-CLXPQG-20221209103108

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191600500
Report Date: 11/08/2022
Date Signed: 11/08/2022 02:46:05 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2021 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210604151340

FACILITY NAME:	NAZARETH HOUSE		FACILITY NUMBER:	191600500
ADMINISTRATOR:	JODI KANOWITZ		FACILITY TYPE:	740
ADDRESS:	3333 MANNING AVENUE		TELEPHONE:	(310) 839-2361
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90064
CAPACITY:	158	CENSUS: 94	DATE:	11/08/2022
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	William "Bill" Boles		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident fell while in care resulting in injury.
Staff did not seek medical attention to resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation to deliver findings. LPA Agard met with Administrator, William “Bill” Boles. LPA Agard explained the purpose of this visit is to deliver the findings for the above complaint allegations.

The investigation consisted of the following: on 06/11/2021, LPA Agard conducted a tour of the facility grounds. The facility is a 2- story building that consists of 136 resident bedrooms, 136 plus resident bathrooms, lobby area, media room, reading room, activity room, dining room, 3 med rooms, 4 elevators, Bistro, and kitchen. On 11/08/2022, LPA requested the following documents: 1) staff and resident roster, and 2) R1’s file. All records were received at the time of visit.

Cont on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

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 11-AS-20210604151340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: NAZARETH HOUSE	FACILITY NUMBER: 191600500
	VISIT DATE: 11/08/2022

NARRATIVE

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The investigation revealed the following… regarding the allegation: Resident fell while in care resulting in injury. It’s being alleged that a resident had a seizure, fell, and hit their head causing an injury. LPA attempted to interview 6 out of a total of 94 residents. 0 out of 5 confirm the allegation. 1 resident was unavailable for an interview. R1 was unavailable. R2 states, “I never witnessed R1 fall.” R3 states, “I don’t recall R1 ever having a fall.” R4-6 were all unable to identify R1 or any residents having a fall that resulted in an injury.

During interviews with staff, LPA interviewed 4 out of a total of 102. 0 out of 4 confirmed the allegation. S1 states, “I don’t know much about the resident or the allegations due to not being here at the time.” S2 states, “I don’t remember R1 falling but it might be possible. I just don’t remember. R1 had a wound on the top of their head but that was due to cancer, not a fall.” S3 states, “I don’t recall R1 falling.” S4 states, “R1 had two falls but that was due to being weak. There were no injuries during that time. During an interview with W1 they state, “I believe R1 fell but I don’t remember when. Think it was last July.”

During a record review, LPA observed an incident report and nurses notes both dated for 05/07/2021 that speaks to resident having a fall. R1 was sent to the hospital for an evaluation. No injuries were noted. Resident was sent to Beverly Hills Rehab Center on 05/10/2021 and was discharged back to the facility on 05/30/2021. Facility states, resident was unable to ambulate do to being weak. Due to R1’s condition, they needed to be rehabilitated before returning back to the facility. LPA reviewed R1’s physician report that does not indicate a history of seizures.

Regarding the allegation: Staff did not seek medical attention to resident in a timely manner. It’s being alleged that the head injury (from the fall) was not being taken care of and caused an infection.” During interviews with residents, 0 out of 5 confirm the allegation. R1 was unavailable. R2 and R3 both denied observing R1 having a fall. R4-6 were all unable to identify R1 or any residents that did not receive medical attention timely. R2 states, “yes, if I needed medical attention, they would get that for me.” R3 states, “oh, absolutely they would get me medical attention.” R5 states, “I consider the staff here as outstanding. Yes, many times they see medical concerns before you can ask about it.”

During interviews with staff, 0 out of 4 confirmed the allegation. S1 states, “I don’t know much about the resident or the allegations due to not being here at the time.” S2 states, “there was never a time R1 went

Cont. 9099

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210604151340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: NAZARETH HOUSE	FACILITY NUMBER: 191600500
	VISIT DATE: 11/08/2022

NARRATIVE

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without medical attention. We always attended to the resident.” S3 states, “I can’t say that’s true. We always get the residents medical attention right away. S4 states, “every time there is a concern with a resident, we send them out.”

During a record review, LPA reviewed on or around 05/06/2021 R1 had a biopsy per an after-visit summary dated for the same day. Per nurses’ notes dated 05/07/2022, the wound was observed to have a smell. On 05/10/2022 R1 entered a rehab for an unrelated reason and returned back to the facility on 05/30/2021. On 06/04/2021 bugs were observed, and resident was sent to the emergency room. Family and medical doctor was notified per nursing notes. On or around 06/04/2021 resident returned back to the facility before returning back to the hospital on 06/05/2021.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

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