191603205-8-29-2024-11-AS-JHAD-D8UPTZ-20240906113644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191603205
Report Date: 08/29/2024
Date Signed: 08/29/2024 10:47:24 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, 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
07/30/2024 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240730163237

FACILITY NAME:	JEANNE JUGAN RESIDENCE		FACILITY NUMBER:	191603205
ADMINISTRATOR:	AGUILOS, ROBERT		FACILITY TYPE:	740
ADDRESS:	2100 SOUTH WESTERN AVENUE		TELEPHONE:	(310) 548-0625
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY:	86	CENSUS: 26	DATE:	08/29/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Sabina Nayberg		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff did not ensure resident was provided fluids resulting in dehydration.
Facility does not ensure that there is sufficient staff on the premises to assist and monitor residents.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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On 08/01/24, at 02:00pm, Licensing Program Analyst (LPA) Perry Scott conducted a 10-Day unannounced visit to the facility and was greeted by Sabina Nayberg, Administrator. LPA explained the purpose of this visit is to gather facility files and to do a Health and Safety tour of the facility.

The investigation consisted of the following: An initial complaint visit was completed by LPA Perry Scott on 08/01/2024. A subsequent visit was completed by LPA Perry Scott on 08/14/2024. LPA investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R5). Resident Roster (Dated: July 2024), Staff Roster (Dated: 06/12/2024), Admission Records (Dated: 08/01/2024), Physicians Report (Dated: 07/11/2023, 08/7/2023 & 03/24/2023) and an SIR (Dated: 07/02/2024) were obtained for residents R1-R3.

Report continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

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-20240730163237

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: JEANNE JUGAN RESIDENCE	FACILITY NUMBER: 191603205
	VISIT DATE: 08/29/2024

NARRATIVE

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The investigation revealed the following: Allegation #1- Facility staff did not ensure resident was provided fluids resulting in dehydration.

The details of the complaint alleged that R1 was recently discharged from the hospital due to dehydration. On 08/14/24, from 12:00pm-3:00pm, LPA interviewed staff (S1-S4) and residents (R1-R5) regarding the allegation. 4 of 4 staff (S1-S4) denied the allegation that the Facility staff did not ensure resident was provided fluids resulting in dehydration. 4 of 4 staff (S1-S4) interviewed stated that R1 has not suffered from dehydration and has not been admitted to the hospital recently for this issue. All staff (S1-S4) stated that they have not had any residents suffering from dehydration and that all residents have access to fluids. Some have water and other fluids in their room, the facility has water stations throughout the facility, and the kitchen pantry is stocked with water and other fluids for hydration. LPA reviewed the most recent Physicians Report (Dated: 08/07/2023) for R1 and did not observe that the resident was admitted to the hospital because of being dehydrated. This was the last available report.

LPA interviewed residents R1-R5 about the allegation and 5 of 5 residents that were interviewed denied the allegation that Facility staff did not ensure resident was provided fluids resulting in dehydration. Resident R1 stated that they have not been admitted to the hospital due to dehydration or any other reason, nor have they suffered from dehydration recently. R2-R5 further state that they have not suffered from dehydration and have bottled water in their rooms and the staff has water stations throughout the facility.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff did not ensure resident was provided fluids resulting in dehydration. Although the allegation 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 allegation is Unsubstantiated.

Allegation #2- Facility does not ensure that there is sufficient staff on the premises to assist and monitor residents.

The details of the complaint alleged that there is only one staff member on the night shift, which makes it difficult to assist and supervise residents. It was reported that two residents had falls in the facility. On 08/14/24, from 12:00pm-3:00pm, LPA interviewed staff (S1-S4) and residents (R1-R5) regarding the allegation. 4 of 4 staff (S1-S4) denied the allegation that the Facility does not ensure that there is sufficient staff on the premises to assist and monitor residents.

Report continued on LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20240730163237

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: JEANNE JUGAN RESIDENCE	FACILITY NUMBER: 191603205
	VISIT DATE: 08/29/2024

NARRATIVE

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S1 stated that many of the residents are independent and don’t require a large staff during the night shift. S1 also stated that there are two caregivers on the night shift with the ratio of residents being 1:8 per caregiver. S1 also stated that only one person had a fall in the facility, and it was R2. R2 fell at her bedside, R2 alerted staff by using the call light at 4:30am, and the caregiver came promptly and attended to the resident. S1 stated that an Unusual Incident Report (SIR: Dated 07/02/2024) was submitted to Community Care Licensing on 07/02/24. S2-S4 stated that they believed there was enough staff on the night shift. LPA reviewed the staff roster (Dated: 06/12/2024) and observed that there were two caregivers on the night shift from 11pm-7:30am. LPA reviewed the resident roster (Dated: July 2024) and observed the facility has 26 residents.

LPA interviewed R1-R5 about the allegation and 5 of 5 residents that were interviewed denied the allegation that the Facility does not ensure that there is sufficient staff on the premises to assist and monitor residents. All residents interviewed stated that they believe it is enough staff to meet the needs of the few residents in the facility. R2 stated that staff came promptly when R2 pressed the call light for assistance when R2 fell. All residents further state that they are happy with the care and supervision provided by the facility.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility does not ensure that there is sufficient staff on the premises to assist and monitor residents. Although the allegation 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 allegation is Unsubstantiated.

Allegation #3- Facility is in disrepair.

The details of the complaint alleged that the facility is in disrepair, has several water leaks in residents’ rooms (Rooms 105, 110, & 122), and the phone lines are not operable. On 08/14/24, from 12:00pm-3:00pm, LPA interviewed staff (S1-S4) and residents (R1-R5) regarding the allegation. 4 of 4 staff (S1-S4) denied the allegation that the Facility is in disrepair. All staff (S1-S4) interviewed stated that there were no leaks in the residents’ rooms nor were there any problems with the phone lines. LPA did a Health and Safety tour of the facility and found it to be in compliance with Title 22, Division 6, Chapter 8 regulations. LPA toured rooms 10, 11, 105, 110, 122 and inspected the rooms as well as the bathroom faucets and toilets for leaks. LPA did not observe any deficiencies. LPA further observed that the phone lines were in working order. LPA was able to call out on the phone lines as well as receive calls.

Report continued on LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20240730163237

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: JEANNE JUGAN RESIDENCE	FACILITY NUMBER: 191603205
	VISIT DATE: 08/29/2024

NARRATIVE

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LPA interviewed R1-R5 about the allegation and 5 of 5 residents that were interviewed denied the allegation that the Facility is in disrepair. All residents interviewed stated that they have not had any leaks in their rooms nor had a problem using the facilities telephone to call out or receive calls.

Based on interviews, and observation, there is insufficient evidence to support the allegation that the Facility is in disrepair. Although the allegation 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 allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted with Sabina Nayberg, Administrator, and a hard copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC9099 (FAS) - (06/04)

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