191600500-1-31-2024-11-AS-SCIS-D4ZT7J-20240506142845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191600500
Report Date: 01/31/2024
Date Signed: 01/31/2024 03:15:13 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20230815095513

FACILITY NAME:	NAZARETH HOUSE		FACILITY NUMBER:	191600500
ADMINISTRATOR:	WILLIAM BOLES JR		FACILITY TYPE:	740
ADDRESS:	3333 MANNING AVENUE		TELEPHONE:	(310) 839-2361
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90064
CAPACITY:	158	CENSUS: 82	DATE:	01/31/2024
		UNANNOUNCED	TIME BEGAN:	12:29 PM
MET WITH:	Josephine Wazir, Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Facility is retaining resident(s) with higher level of care needs.

INVESTIGATION FINDINGS:

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On 1/31/24, Licensing Program Analyst (LPA) Felisa Shirley and LPM Stephanie Cifuentes conducted an unannounced subsequent visit to this facility. LPA was met by Administrator, Josefina Wazir, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility.

The investigation consisted of the following:
On 8/23/23, The investigation consisted of the following: LPA Shirley conducted interviews with the Administrator, Josephine “Fina” Wazir (S1) Staff (S2 – S8) and residents (R1 – R5). LPA requested, received and reviewed copies of the following documents: Staff and Resident Rosters, resident files which contained, Preplacement Appraisals, Physician’s Reports, Resident Identification and Emergency Information, Needs and Services Plan, Elopement Risk Assessment, and Acknowledgment/Approval of Use of Egress Alert Device.
Con'd on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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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Control Number 11-AS-20230815095513

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: NAZARETH HOUSE	FACILITY NUMBER: 191600500
	VISIT DATE: 01/31/2024

NARRATIVE

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The investigation revealed the following:

Allegation: Facility is retaining resident(s) with higher level of care needs

On 8/21/2023 LPA Shirley reviewed the facility file at the El Segundo Office. LPA Shirley noted that facility does not have dementia care as part of its plan of operation. On 8/23/2023 LPA Shirley reviewed facility files at facility listed above. LPA observed that the file for R1 contained the following documents which listed dementia as a diagnosis: Preplacement Appraisal Information, dated 7/19/22 and Physician’s Report for Residential Care Facilities For the Elderly, dated 7/19/22. R1’s Needs and Services plan, dated 8/4/2022 page 2 states, “Provide escort and reminders to and from activities” and an Elopement Risk Assessment signed 6/8/23 which indicated R1 was an elopement risk. LPA Shirley conducted a walkthrough of the facility and found that there is no secured perimeter. LPA interviewed Staff1-Staff 8 and asked if facility had a memory care unit. Of those interviewed, 7 out of 8 stated the facility does not have a memory care unit.
Based on interviews, file review, and tour of facility there is sufficient evidence to support the allegation: “Facility is retaining resident(s) with higher level of care needs”. The facility does not have an approved dementia care operation, nor do the facility premises have a secured perimeter. The preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 6 are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230815095513

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: NAZARETH HOUSE	FACILITY NUMBER: 191600500
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/14/2024 Section Cited CCR 87208(c)	1 2 3 4 5 6 7	87208 Plan of Operation A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will review regulation 87705: Care of persons with Dementia and submit in writing via email or fax their understanding of the regulation by the POC due date and submit an addendum to their plan of operation if they wish to retain residents with Dementia.
	8 9 10 11 12 13 14	Based on records review and interviews R1 was admitted to facility with Dementia, which required a higher level of care than the facility could provide as dementia information was not included on the plan of operation. This poses a potential threat to residents in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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