<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602106
Report Date: 07/21/2023
Date Signed: 07/21/2023 11:12:36 AM

Unsubstantiated


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
09/30/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210930114609
FACILITY NAME:BEVERLY HILLS CARMEL RETIREMENT HOTELFACILITY NUMBER:
197602106
ADMINISTRATOR:JOY ALVARADOFACILITY TYPE:
740
ADDRESS:8750 BURTON WAYTELEPHONE:
(310) 278-9720
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:200CENSUS: 55DATE:
07/21/2023
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Bernice Polanco, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained multiple fractures while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Bernice Polanco, Administrator.

The investigation was conducted by Investigator Dennis Douglas, which consisted of following, Interviews and Record reviews. LPA Soto requested the following documents on 10/01/21: R#1 Emergency ID form, no fall risk documents, Needs and Services Plan, Medication List, Admissions Agreement, 2 -SIRs for fall incidents, Monitoring List, Pre-Appraisals, Physician's Report, Verbal request letter, and Letter of contact with Cedar Sinai Hospital. Staff 1-2, Applications and training's, S#3 application only.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
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 5
Control Number 11-AS-20210930114609
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: 07/21/2023
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
Based on IB’s investigation, the investigation revealed the following. For Allegation 1 – Resident sustained multiple fractures while in care. During the investigation, it was disclosed that facility R#1, that R#1 had experienced two separate unwitnessed falls in his room within a span of two weeks. The initial fall occurred on 09/14/21. In that incident, R#1 was discovered on the floor of R#1 room by a caregiver who called for assistance. A facility Med Tech came to the room and assisted R#1. The MedTech assessed R#1 and determined R#1 was okay and did not need EMS (Emergency Medical Services). R#1 advised Staff that R#1 himself was okay. During the investigation, it was disclosed by staff that on Friday 09/24/21, X- rays were ordered and requested for R#1, because they noticed something was wrong with R#1. R#1 stayed in bed and asked for pain pills. R#1 did not specify why R#1 wanted them. The X-rays were performed at the facility on Monday 09/27/21. It was disclosed that R#1 family member, who is also the designated power of attorney, requested they wait for the X-ray results before taking R#1 to the hospital. The facility agreed. However, R#1 sustained a second fall the following day on 09/28/21. In that incident, R#1 was discovered on the floor by the Med Tech. R#1 advised the Med Tech R#1 was fine. The Med Tech assessed R#1 and again determined that R#1 did not need EMS (Emergency Medical Services). R#1 was ultimately taken to the hospital the following day, on 09/29/21, per R#1’s doctor. R#1 was discovered to have multiple fractures and complained of right sided chest pain due to falls 2 weeks prior. Within the 2 falls R#1 denied needing medical help and did not disclose why R#1 was asking for pain medication, staff made their assessment, did not see any visual signs of injury and determined R#1 did not need EMS. R#1 had half beds rails on his bed, to prevent falls from occurring. R#1 attempted to get up from his bed on his own, in both occasion, R#1 did not ask for help. It cannot be determined is R#1 suffered injuries from the 1st or 2nd fall or he sustained in some other incident prior to the falls. Therefore, based on all the information obtained during the investigation, the allegation is unsubstantiated.

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

An exit interview was conducted with Bernice Polanco , Administrator, and a hard copy of report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/30/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210930114609

FACILITY NAME:BEVERLY HILLS CARMEL RETIREMENT HOTELFACILITY NUMBER:
197602106
ADMINISTRATOR:JOY ALVARADOFACILITY TYPE:
740
ADDRESS:8750 BURTON WAYTELEPHONE:
(310) 278-9720
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:200CENSUS: DATE:
07/21/2023
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Bernice Polanco, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not seek resident timely medical attention.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Bernice Polanco, Administrator.

The investigation was conducted by Investigator Dennis Douglas, which consisted of following, Interviews and Record reviews. LPA Soto requested the following documents on 10/01/21: R#1 Emergency ID form, no fall risk documents, Needs and Services Plan, Medication List, Admissions Agreement, 2 -SIRs for fall incidents, Monitoring List, Pre-Appraisals, Physician's Report, Verbal request letter, and Letter of contact with Cedar Sinai Hospital. Staff 1-2, Applications and training's, S#3 application only.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210930114609
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: 07/21/2023
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
Allegation - Facility did not seek resident timely medical attention. During the investigation, it was disclosed that facility R#1, indeed experienced two separate unwitnessed falls in his room within a span of two weeks. The initial fall occurred on 09/14/21 and the 2nd fall on 09/28/21. On both incidents, Med tech’s assessed R#1 and determined that R#1 did not need EMS (Emergency Medical Services.) The X-rays were performed at the facility on Monday 09/27/21. R#1’s doctor advised staff to take R#1 to the hospital, 2 weeks after the initial fall. R#1 was discovered to have multiple fractures and complained of right sided chest pain due to falls 2 weeks prior. Therefore, based on all the information obtained during the investigation, the allegation is substantiated.

Based on IB’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210930114609
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: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2023
Section Cited
CCR
87405(D)(1)(1)
1
2
3
4
5
6
7
Knowledge of the requirements for providing care and supervision appropriate to the residents. This was not met as evidence by: Facility sent R#1 to hospital 2 weeks after initial fall.

1
2
3
4
5
6
7
Administrator to write a plan as how to ensure residents get timely medical help. Send plan to LPA on or before POC due date,
8
9
10
11
12
13
14
Which poses a potential health and safety risk for persons in care.
8
9
10
11
12
13
14
Type B
08/01/2023
Section Cited
CCR
87466
1
2
3
4
5
6
7
The licensee shall ensure that residents are regularly observed for changes in physical,...This was not met as evident by:Facility sent R#1 to hospital 2 weeks after initial fall.
1
2
3
4
5
6
7
Administrator to write a plan as how to ensure resdients more often when fall incident occur. Send plan to LPA on or before POC due date,
8
9
10
11
12
13
14
Which poses a potential health and safety risk for persons 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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5