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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191600749
Report Date: 03/05/2021
Date Signed: 03/12/2021 08:32:30 AM



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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2020 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200601115731
FACILITY NAME:VILLA SORRENTOFACILITY NUMBER:
191600749
ADMINISTRATOR:CARLA CHANFACILITY TYPE:
740
ADDRESS:23450 MADISONTELEPHONE:
(310) 539-6826
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:145CENSUS: 74DATE:
03/05/2021
UNANNOUNCEDTIME BEGAN:
02:44 PM
MET WITH:Carla ChanTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is infested with roaches.
INVESTIGATION FINDINGS:
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On 3/5/2021, Licensing Program Analyst (LPA)/ Campos, initiated a subsequent complaint investigation visit to deliver findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with Carla Chan, Administrator. The investigation consisted of the following: LPA Williams conducted telephone interviews with (5) staff members on 6/10/20 and also conducted client teleconference/ zoom interviews with (10) clients on 6/10/20. In addition, on 6/11/20, LPA conducted a telephone/video inspection, of the facilities’ physical plant and food supply for health and safety. Areas covered, in the teleconference, included: the facilities' physical plant, and food supply. LPA also reviewed the following documents provided by Villa Sorrento Administrator Carla Chan: current staff/resident roster, house rules, resident emergency contact information,pre-placement appraisal, needs and service plans, physician’s report, medications, medication logs, pest control contract and invoices for 2020.

Report continued on LIC 9099
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
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 8
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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2020 and conducted by Evaluator Susan Campos
COMPLAINT CONTROL NUMBER: 11-AS-20200601115731

FACILITY NAME:VILLA SORRENTOFACILITY NUMBER:
191600749
ADMINISTRATOR:CARLA CHANFACILITY TYPE:
740
ADDRESS:23450 MADISONTELEPHONE:
(310) 539-6826
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:145CENSUS: 74DATE:
03/05/2021
UNANNOUNCEDTIME BEGAN:
02:44 PM
MET WITH:Carla ChanTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff failed to assist residents in a timely manner.
Facility staff are not keeping the facility clean.
Insufficient staffing.
Facility staff handle residents in a rough manner.
Staff mishandle residents' medication.
Staff failed to meet residents' needs.
INVESTIGATION FINDINGS:
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On 3/5/2021, Licensing Program Analyst (LPA)/ Campos, initiated a subsequent complaint investigation visit to deliver findings for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with Carla Chan, Administrator. The investigation consisted of the following: LPA Williams conducted telephone interviews with (5) staff members on 6/10/20 and also conducted client teleconference/ zoom interviews with (10) clients on 6/10/20. In addition, on 6/11/20, LPA conducted a telephone/video inspection, of the facilities’ physical plant and food supply for health and safety. Areas covered, in the teleconference, included: the facilities' physical plant, and food supply. LPA also reviewed the following documents provided by Villa Sorrento Administrator Carla Chan: current staff/resident roster, house rules, resident emergency contact information,pre-placement appraisal, needs and service plans, physician’s report, medications, medication logs, pest control contract and invoices for 2020.

Report continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20200601115731
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
MONTERY PARK, CA 91754
FACILITY NAME: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 03/05/2021
NARRATIVE
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Allegations: Facility staff failed to assist residents in a timely manner.

The investigation revealed, per LPA Williams interviews, with (5) staff members, and (10) clients from the Villa Sorrento, and review of facility documents that the facility assists residents in a timely manner. In addition, S1 informed LPA, that the facility staff assist residents timely, and is not aware of a staff person that does not does not assist residents in a timely manner nor has a resident informed S1 that they did not receive assistance in a timely manner. The LPA interviewed (5) Villa Sorrento staff persons and 5 of the 5 staff members interviewed, informed LPA, that the staff at the facility assist residents in a timely manner. Furthermore, LPA interviewed (10) residents, and 10 of 10 residents interviewed, informed LPA, that the facility staff provides services in a timely manner, and that they are happy with the staff response time.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Facility staff failed to assist residents in a timely manner ”.

Allegations: Facility staff are not keeping the facility clean.

The investigation revealed, per LPA Williams interviews, with (5) staff members, and (10) clients from the Villa Sorrento facility, and review of facility documents, that the facility is kept clean on a daily basis. S1 informed LPA that there is a housekeeping department, that is responsible for cleaning all resident rooms, and facility common areas. Furthermore, S1, has not been informed from a staff person or resident that the facility is not clean. S1 states if there were concerns of cleanliness, then they could be immediately addressed by the housekeeping staff. The LPA interviewed (5) Villa Sorrento staff persons and 5 of the 5 staff members interviewed, informed LPA, that the facility is clean, and that housekeepers clean the facility everyday. Furthermore, LPA interviewed (10) residents, and 10 of 10 residents interviewed, informed LPA, that the facility is clean.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Facility staff are not keeping the facility clean ”.

Report continued on LIC 9099C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20200601115731
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
MONTERY PARK, CA 91754
FACILITY NAME: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 03/05/2021
NARRATIVE
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Allegation: Insufficient staffing.

The investigation revealed, per LPA Williams interviews, with (5) staff members, and (10) clients from the Villa Sorrento, and review of facility documents, that the facility does have sufficient staffing. In addition, S1 informed LPA, that the facility has scheduled staff assisting and helping residents in all workshifts. Also S1, informed LPA that the staff are a team, and if a staff person needed assistance, then they would get support from another staff person. In addition, S1 informed LPA that has not been informed from staff or residents in the facility that there is insufficient staffing to care for the residents. The LPA interviewed (5) Villa Sorrento staff persons and 5 of the 5 staff members interviewed, informed LPA, that the staff at the facility are sufficient to care for the resident needs. Furthermore, LPA interviewed (10) residents, and 10 of 10 residents interviewed, informed LPA, that there are sufficient staff in the facility, to assist the residents with their needs, and also (10) residents interviewed, 10 of 10 residents, informed LPA that the facility staff are helpful.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Insufficient staffing”.

Allegation: Facility staff handle residents in a rough manner.

The investigation revealed, per LPA Williams interviews, with (5) staff members, and (10) clients from the Villa Sorrento facility, and review of facility documents, that the facility does not handle residents in a rough manner. In addition, S1 informed LPA, that the facility does not tolerate, any staff person, act in a rough manner to a resident, and would not allow it. S1 also stated that does not know or heard of a staff person, that has treated a resident in a rough manner. The LPA interviewed (5) Villa Sorrento staff persons, and 5 of the 5 staff members interviewed, informed LPA, that they do not treat residents in the facility, in a rough manner, and also that they do not know of a staff member, in the facility, that treats residents in a rough manner. Furthermore, LPA interviewed (10) residents, and 10 of 10 residents interviewed, informed LPA, that the facility staff have never treated them in a rough manner and also that they have never been hurt by a facility staff member.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Facility staff handle residents in a rough manner ”.

Report continued on LIC 9099C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20200601115731
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
MONTERY PARK, CA 91754
FACILITY NAME: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 03/05/2021
NARRATIVE
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Allegation: Staff mishandle residents' medication.

The investigation revealed, per LPA Williams interviews, with (5) staff members, and (10) clients from the Villa Sorrento facility, and review of facility documents, that the facility does not mishandle residents' medication. S1 informed LPA, that the facility staff follow the resident's MAR when dispensing medication. And also that staff provide residents with the required medication when prescribed by their physician on the time required. Furthermore S1 states that staff follow procedures, for assistance in dispensing resident medication. S1 informed LPA that did not receive a report from staff or residents of the facility, that their medication has been mishandled by the staff. The LPA interviewed (5) Villa Sorrento staff persons and 5 of the 5 staff members interviewed, informed the LPA, that they are not aware of a staff person, that has provided a resident with wrong medication or that did not assist resident with medication. Furthermore, LPA interviewed (10) residents, and 10 of 10 residents interviewed, informed LPA, that the facility staff, provide medication, to the residents, and 10 or 10 residents, informed LPA, that they have never been provided incorrect medication.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff mishandle residents' medication ”.

Allegation: failed to meet residents' needs.

The investigation revealed, per LPA Williams interviews, with (5) staff members, and (10) clients from the Villa Sorrento facility, and review of facility documents, that the facility does meet the residents needs. In addition, S1 informed LPA, that the facility staff provide the residents with the services needed for care. The residents are assessed during the admission process, and also the needs assessment plan is developed with the services needed for care, and is updated every year or sooner, if needed. S1 states that a staff person, resident or family members have not reported to S1 that there a residents need are not being met. If it were brought to my attention, then it would be addressed immediately.
The LPA interviewed (5) Villa Sorrento staff persons and 5 of the 5 staff members interviewed, informed LPA, that the staff at the facility assist the needs of the residents. Also 5 of the 5 staff members interviewed informed the LPA that all residents in the facility have a schedule, for the services that a resident needs. Furthermore, LPA interviewed (10) residents, and 10 of 10 residents interviewed, informed LPA, that the facility staff provides services needed for their care, and (10) residents informed LPA that the facility staff are

Report continued on LIC 9099C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20200601115731
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
MONTERY PARK, CA 91754
FACILITY NAME: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 03/05/2021
NARRATIVE
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available to them when needed, and also assist them when requested.

Based on information gathered, LPA did not find sufficient evidence to support allegation " failed to meet residents' needs”.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. A telephonic exit interview was conducted with Carla Chan, Administrator, and a hard copy of a LIC 9099 was provided via email for signature.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20200601115731
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
MONTERY PARK, CA 91754
FACILITY NAME: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 03/05/2021
NARRATIVE
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Allegation: Facility is infested with roaches.

The investigation revealed, per LPA Williams interviews, with (5) staff members, and (10) clients from the Villa Sorrento, and review of facility documents that the facility has cockroaches. S1 informed LPA, that the facility has a contract for monthly pest control services, and a pest control technician, comes to the facility on a monthly basis to spray the facility for pests and insects. S1 provided LPA with facility pest control contract, and invoice statements of pest control services conducted in 2020/ 2021. The LPA interviewed (5) Villa Sorrento staff persons and 4 of the 5 staff members interviewed, informed LPA, that the they have not seen cockroaches in the facility. LPA interviewed (10) residents, and 7 of the 10 residents interviewed, informed LPA, that they have seen cockroaches in the facility.

Based on information gathered, LPA found sufficient evidence to support allegation " Facility is infested with roaches ”.

On 6/10/20, LPA Williams, conducted interviews with 10 residents, and 7 of 10 residents interviewed, informed LPA that there are cockroaches in the facility.

Based on LPA observations and interviews which were conducted record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (1) are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Carla Chan, Administrator, and a hard copy of a LIC 9099 and LIC 9099D was provided via email for signature.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20200601115731
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
MONTERY PARK, CA 91754

FACILITY NAME: VILLA SORRENTO
FACILITY NUMBER: 191600749
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Administrator will provide LPA, with a copy of a plan to eliminate (pests) cockroaches in the facility.

Documents are to be faxed to LPA fax number (323) 981-1781

POC Due Date is 3/12/21
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Based on interview and record review, during investiigation, 7 of 10 residents interviewed informed LPA that facility has cockroaches, licensee failed to keep facility clean and safe, which posed a potential health risk to residents in care.
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 8