197602106-8-18-2020-11-AS-EMAZ-BU6MSH-20201007095158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602106
Report Date: 08/18/2020
Date Signed: 08/18/2020 04:44:52 PM

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
07/29/2020 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200729084029

FACILITY NAME:	BEVERLY HILLS CARMEL RETIREMENT HOTEL		FACILITY NUMBER:	197602106
ADMINISTRATOR:	BORIS TAMASI		FACILITY TYPE:	740
ADDRESS:	8750 BURTON WAY		TELEPHONE:	(310) 278-9720
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	200	CENSUS: 69	DATE:	08/18/2020
		UNANNOUNCED	TIME BEGAN:	12:57 PM
MET WITH:	Joy Alvarado		TIME COMPLETED:	03:27 PM

ALLEGATION(S):

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Facility staff physically assaulted resident

INVESTIGATION FINDINGS:

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On 08/18/20, Licensing Program Analyst, LPA/Ernand Dabuet initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Joy Alvarado/Administrator at this facility.

The investigation consisted of the following: Telephone/video interviews conducted with staff, residents, and family members. Copies were obtained of current staff/resident roster, (R1's) pre-placement appraisal, physician’s report, emergency contact information, needs and service plan, medications, (S1's) personnel file, and In-Service Training and Internal Investigation Records. A plant inspection of the facility.

Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020

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 3

Control Number 11-AS-20200729084029

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: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
	VISIT DATE: 08/18/2020

NARRATIVE

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Allegation: Facility staff physically assaulted resident

It is alleged Resident #1 (R1) was physically assaulted by staff. Interviews were conducted with residents (R1-R7) staff (S1-S8), family members (W1-W3) and found there is no evidence to support “Facility staff physically assaulted resident.” The Department obtained (R1’s) service records in which: Preplacement Appraisal, Progress Notes, Emergency Form, Medication List, Physician’s Report, Photographs, and Narrative from an Internal Investigation Report were reviewed. In addition, (S1’s) personnel file and In-Service Training for Elder Abuse were provided and accounted for and reviewed.

An interview with Staff #1 (S1) denies having any knowledge or being involved with (R1) in any form of physical assault or abuse. An interview with (R1) claims (S1) grabbed, slapped, punched, choked, and dragged her in a physical form. An interview with both complainant (W1) and (R1) unable to provide an accurate date and time when this alleged incident occurred. (R1) reports that the incident could have happened prior to the Jewish Passover holiday this year. During the interview, (R1) would go in and out the order of sequence when she would explain the conditions that happened with her. (R1) was also uncertain of the occurrences. (R1) and complainant (W1) both gave conflicting accounts of how (S1) did or did not have her hands wrapped when she struck (R1). (R1) reports (S1) did not have anything covering her hands, while (W1) claims (S1) had her hands wrapped with an object and unable to leave marks on (R1's) body. (R1) did not seek medical attention and showed no signs of physical trauma that may include bruises, welts, scratches, fractures, or other injuries that could explain or match (R1’s) claims. (R1) and (W1) did not have physical evidence or witnesses.

Interviews with (S1-S8) all verified no unusual incidents were reported during that time and body examines are done twice daily and any relevant welts on (R1’s) body would have been reported or indicated on (R1’s) progress notes. An interview with a family member (W2) reports he would make frequent visits with (R1) as he would assist with medical appointments and had not observed any signs of physical assault. (W2) reports he had no concerns with (R1’s) care and that the staff are exceptional. (W2) claims he did not see the staff have any frictions with residents.

Evaluation Report continues on LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200729084029

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: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
	VISIT DATE: 08/18/2020

NARRATIVE

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The Department conducted interviews with residents (R2-R7) who received direct care from (S1), each resident gave a positive response to the care received and did not have any health or safety concerns.

The facility Administrator conducted its own Internal Investigation on 07/20/20. The facility notified Community Care Licensing (CCL), Ombudsman (LTCO), and Law Enforcement Agency. On 08/11/20 the investigation concluded, and it resulted in unsubstantiated. The Department contacted Law Enforcement and was informed that no report was taken as there were no life-threatening physical signs that would constitute elder assault or abuse. A plant inspection was conducted and found the facility does not have video surveillance equipment installed.

The investigation consisted of an inspection of facility, observation, review of services records, internal investigation reports, and interviews conducted all resulted in no physical assault in which would threaten the physical health, safety, or welfare of the persons in care at this license facility.

Based on information gathered, the Department did not find sufficient evidence to support allegation “Facility staff physically assaulted resident.”

Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged allegation is valid did or did not occur. Therefore, the allegation is "unsubstantiated.”

A telephonic exit interview was conducted with Joy Alvarado, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020

LIC9099 (FAS) - (06/04)

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