191600500-8-13-2024-11-AS-EMAZ-D8ZPPH-20240911112935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191600500
Report Date: 08/13/2024
Date Signed: 08/13/2024 11:58:34 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
08/14/2023 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20230814112634

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: 79	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Josephine “Fina” Wazir		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Questionable death.
Unqualified staff are providing care and supervision to residents.

INVESTIGATION FINDINGS:

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On 08/13/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to the facility listed above to deliver findings for a complaint. LPA met with Administrator, Josephine “Fina” Wazir, and the purpose of today’s visit was explained.
LPA conducted previous visits that consisted of: On 08/15/23, LPA conducted a facility tour, interviewed Chief Executive Officer and Regional Operations Manager of the company, and received pertinent documents related to the investigation. LPA Gibbs reviewed, and received copies of the facilities staff and resident Roster, staff training records of staff who provide care for residents diagnosed with Dementia, Plan of Operation related to Care of Persons with Dementia, resident Identification and Emergency Information, Preplacement Appraisal, Physician's Report, Physician’s Orders, Hospice Medication Profile, Needs and Services Plan, and staff notes. On 03/13/24, LPA toured the facility, interviewed Staff (S3-S6), interviewed Resident (R2-R9), and received additional documents pertinent to the investigation. The documents include Resident R1’s Admission Agreement, Narrative Charting notes for R1, and Hospice notes.
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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 4

Control Number 11-AS-20230814112634

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: NAZARETH HOUSE	FACILITY NUMBER: 191600500
	VISIT DATE: 08/13/2024

NARRATIVE

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Allegation: Questionable Death
The complaint allegation alleges that due to untrained staff transferring R1 to the hospital for dementia related behavior led to confusion and transfer trauma resulting in R1’s death.
During record review, LPA received and reviewed a copy of the staff Narrative Charting for R1, upon review LPA observed R1 was transferred to UCLA (Westwood) Hospital for a needed mental health evaluation on 04/19/23. Additionally, LPA observed UCLA ER contacted the facility on 04/20/23, to inform them they were transferring R1 to Glendora Hospital for admission. During interviews with W1, LPA was informed R1 was being transferred due to UCLA being at capacity. LPA reviewed the discharge document from Glendora Hospital and observed R1 was treated at Glendora Hospital from 04/20/23 till 04/22/23 due to a neurocognitive disorder. Glendora Hospital then transferred R1 to College Medical Center on 04/22/23 due to R1 requiring additional medical care. LPA reviewed the discharge documents for R1 and observed that R1 was diagnosed with acute hypoxic respiratory failure and found to have a dissection at the distal part of the aortic with an additional diagnosis of pneumonia. R1 received care at College Medical Center till discharged on 04/26/23. During R1’s admission at College Medical Center, the family opted for hospice care and comfort measures only, due to R1s worsening health status. After discharge, R1 was transported back to the facility on 04/26/23. Upon review of R1’s Death Certificate, LPA observed it stated the immediate cause of death to be “Cardiopulmonary Arrest.”

(2) Continued On LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230814112634

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: NAZARETH HOUSE	FACILITY NUMBER: 191600500
	VISIT DATE: 08/13/2024

NARRATIVE

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During interviews with Staff S4-S6, were asked what the procedure was if a resident is exhibiting agitation and aggressive behavior, three (3) out of three (3), stated the physician is notified, PRN is provided (if prescribed), and if needed sent to the hospital for a medication and psychiatric evaluation.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Unqualified staff are providing care and supervision to residents.

The complaint allegation alleges the facility accepted a resident with a diagnosis of dementia without a Memory Care program in place and that staff lack the training and support to aid residents with dementia.
During file review of the facility’s Plan of Operation, LPA observed the facility has a Plan of Operation Related to Care of Persons with Dementia beginning on page 120. During resident file review, LPA received and reviewed R1’s Physician’s Report conducted on August 19, 2022, prior to R1’s admission to the facility on 09/07/22, the Physician’s Report does not list dementia as primary or secondary diagnosis. LPA observed the report indicated R1 has a “Mild Cognitive Impairment.” Additionally, LPA reviewed ten (10) Staff Training Logs consisting of caregivers and med techs and observed ten (10) out of ten (10) had the required training in dementia.

(3) Continued On LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20230814112634

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: NAZARETH HOUSE	FACILITY NUMBER: 191600500
	VISIT DATE: 08/13/2024

NARRATIVE

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During interviews with Staff (S1-S6), they were asked if they receive Dementia Care Training, six (6) out of six (6), stated they participate in training on Relias annually and they have participated in In-Service Training regarding care for residents with dementia. During interviews with Residents R2-R9, they were asked if they believe staff are trained to provide appropriate care to all the residents, eight (8) out of eight (8) stated yes, the staff are appropriately trained to care for residents.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

During today’s visit LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Josephine “Fina” Wazir, and a copy of this report was provided.

(4)

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4