197602106-12-7-2023-11-AS-UCOL-D3BUVR-20240313155535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602106
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:17:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
11/29/2023 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 11-AS-20231129152826

FACILITY NAME:	BEVERLY HILLS CARMEL RETIREMENT HOTEL		FACILITY NUMBER:	197602106
ADMINISTRATOR:	PULANCO, BERNICE		FACILITY TYPE:	740
ADDRESS:	8750 BURTON WAY		TELEPHONE:	(310) 278-9720
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	200	CENSUS: 50	DATE:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Pulanco Bernice		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff do not provide adequate food service to residents.
Staff do not ensure the facility is clean.
Staff do not administrer residents' medications as prescribed
Staff do not ensure residents have adequate night time supervision.

INVESTIGATION FINDINGS:

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On 12/07/23, Licensing Program Analyst (LPA) Antonine Richard conducted an initial complaint investigation for the allegations listed above. LPA was greeted by receptionist Tony Mitchell. Administrator Bernice Pulanco arrived shortly and later joined by Regional Executive Director Robin Culver with the visit. LPA explained the purpose of today's visit.

The investigation consisted of the following: LPA Richard toured the physical plant with the Regional Executive Culver and Pulanco. LPA Richard reviewed and requested copies of staff and client's records. LPA interviewed six residnts,(R1-R6) and six staff (S1-S6). LPA Richard requested and reviewed and collected facility documents. Resident Information sheet, roster, MAR, Menu for the month, General Cleaning Schedule.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231129152826

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
	VISIT DATE: 12/07/2023

NARRATIVE

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The investigation revealed the following:

Regarding allegations: Staff do not provide adequate food service to residents.

On 12/07/23, LPA interviewed six staff (S1-S6) about the allegation above, all six staff agreed the allegation is not true, some of the resident like to have a portion of food served to them. The staff also reported they do ask the residents if they like to have more food. During today investigations, LPA and Administrator observed residents having breakfast, the proportion of the food served was adequate a lot. Based on Observation and interviews there is not sufficient evidence to support the alleged allegation: There is not preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation staff do not provide adequate food service to residents is unsubstantiated.

Regarding allegation: Staff do not ensure the facility is clean.

On 12/07/23, LPA interviewed six staff(S1-S6) all staff indicated that residents bedrooms were sanitary, during the investigation, LPA observed the residents bedrooms, bed sheets, the floor, the wall are cleaned. The water fountain in lobby and in the dining room had no mold, stain, and calcium surrounding the water faucet. About the allegation above all the staff agreed the allegation is not true. LPA interviewed six Residents (R1-R6), all residents stated the facility is in sanitary condition. Based on observation, interviews there is not sufficient evidence to support the alleged allegation, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation staff do not ensure the facility is clean is Unsubstantiated.

Regarding allegation: Staff do not administer residents' medications as prescribed.

On 12/07/23, LPA interviewed six staff (S1-S6), 3 out 6 staff stated that they assisted with the medications the way the doctor prescribed the medication. LPA interviewed the nurse (S6) stated all the medications are being recorded and signed in the MAR after the medication have been administered. LPA reviewed the records (MAR) and found it to be in order. LPA Interviewed six residents (R1-R6) 4 out 6 residents stated they don't need assistance with their medications. However, if they do need help the nurse does help them. The Residents (R2-R3) stated they do not have a problem how the facility administers its medications. Based on records reviewed and interviewed there is not sufficient evidence to support the alleged allegation there is not a preponderance of evidence to prove the allegation staff do not administer residents medications as prescribed. Therefore the allegation is Unsubstantiated.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231129152826

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
	VISIT DATE: 12/07/2023

NARRATIVE

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Regarding allegation: Staff do not ensure residents have adequate nighttime supervision.

On 12/07/23, LPA Richard interviewed six staff (S1-S6) Interviews conducted with both administrators, S1 – S2, stated that there is night supervision. There are 2 care givers, 1 Med aide, and the Nurse supervisor is on call for the night shift. There is also someone at the front desk until 10:00 PM every day. Interviews with residents (R1-R6), did not know about night supervision. LPA Richard reviewed the staff schedule, front desk schedule, and Med aide schedule. there is enough night time supervision at the facility.

Based on interviewed, records reviewed There is enough night supervision for the facility. 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 alleged allegation staff do not ensure residents have adequate night time supervision is unsubstantiated.

An exit interview was conducted with Bernice Pulanco, Administrator, and Robin Culver, Regional Executive Director, and a copy of the report was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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