197602106-6-11-2021-11-AS-MVAO-C4PQHK-20210707121117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602106
Report Date: 06/11/2021
Date Signed: 06/11/2021 01:04:16 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2020 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20201006100914

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:	DATE:	06/11/2021
		UNANNOUNCED	TIME BEGAN:	12:34 PM
MET WITH:			TIME COMPLETED:	12:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Ilegal Eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jennifer Jones initiated a subsequent complaint investigation for the allegation listed above and delivered findings. During today’s visit, LPA Soto met with administrator, Bernice Pulanco and delivered findings.

An initial 10day complaint investigation was conducted on 10/07/2020; LPA Cardenas conducted a tele-visit via facetime and interviewed facility administrator, Joy Alvarado. LPA Cardenas requested that a copy of resident and staff roaster as well as additional resident documentation pertinent to the allegation is emailed to LPA. During today’s visit on 06/11/21, LPA met with the administrator, Bernice Pulanco and delivered findings.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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 3

Control Number 11-AS-20201006100914

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
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
	VISIT DATE: 06/11/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The allegation revealed the following. For allegation: (Illegal eviction) It is being alleged that a resident was dropped off at the hospital and was not able to return to the facility due to needing a higher level of care. RP revealed during an interview with LPA Cardenas that the resident was admitted to the hospital on 10/05/20 due to pain and a wound not healing. According to the RP, R1 was admitted to ER on 10/1/2020 due to un-stage able wound and discharged on 10/02/2020 with the wounds in the same stage on from most recent visit and the facility took him back. The RP also revealed that on 9/26/2020 RP went to Cedar Sinai and then transferred to Kaiser. During that time R1’s had an unstageable pressure wound on the right heel. The administrator Joy Alvarado revealed to LPA during her interview that R1 was not evicted. The administrator stated that on 10/02/2020 the facility received a call from a Kaiser doctor stating that R1 was ready to be discharged. At that time, the Facility suggested for R1 to go to the skilled center due to Home Health Care not being able to heal the wound. R1’s family member revealed during an interview LPA Cardenas that R1 didn’t receive an eviction notice and the facility decided that R1’s condition was prohibited and so they sent him to the hospital because of it. R1’s family member stated that the facility said they couldn’t take care of R1 nor take him back until his wounds was healed. The administrator revealed to LPA Cardenas that a reassessment was not done on R1 indicating that his wound was getting worse and the facility was unable to treat it nor did the administrator contact R1’s family regarding his condition.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, 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 (8) are being cited on the attached LIC 9099D.

A exit interview was conducted with Administrator, Bernice Pulanco and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20201006100914

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
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/11/2021 Section Cited CCR 87463	1 2 3 4 5 6 7	87463-(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:	1 2 3 4 5 6 7	Administrator to create a plan in order to avoid this in hte future. Email, fax. mail POC by 06/18/21.
	8 9 10 11 12 13 14	3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This was not mey as evidenved by Based on observations and interviews due to higher level of carewhich poses a potetial health, safety to persons in care.	8 9 10 11 12 13 14
Type B 06/11/2021 Section Cited CCR 87405	1 2 3 4 5 6 7	87405-h)The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission	1 2 3 4 5 6 7	Administrator to create a plan in order to avoid this in hte future. Email, fax. mail POC by 06/18/21.
	8 9 10 11 12 13 14	Appraisals, specified in Section 87457, Pre-admission Appraisal, and Reappraisal, as specified in Section 87463. This was not met as evidenced by Based observations and interviews no pre appraisal done which poses a potential health, safety to prsons in care	8 9 10 11 12 13 14

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3