197602934-5-12-2022-11-AS-UCOL-CEHLU5-20220517090318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602934
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:55:45 PM

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
09/02/2021 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210902125751

FACILITY NAME:	AYRES RESIDENTIAL CARE HOME-CENTURY CITY		FACILITY NUMBER:	197602934
ADMINISTRATOR:	MICHAEL GABAI		FACILITY TYPE:	740
ADDRESS:	10363 CALVIN AVE		TELEPHONE:	(310) 475-6484
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90025
CAPACITY:	6	CENSUS: 6	DATE:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Amalia Concepcion, Manager		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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1) Staff did not follow physician's orders for administration of medication(s)

INVESTIGATION FINDINGS:

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On 05/12/2022 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent visit to deliver findings regarding the allegation listed above. Upon arrival, LPA met with Amalia Concepcion, Manager and the purpose of the visit was explained.

On 09/07/2021 Licensing Program Analyst (LPA) Troy Agard initiated a 10-day complaint investigation for the allegation listed above. LPA Agard met with Manager, Amalia Concepcion, and the purpose of the visit was explained.

The investigation consisted of the following: a physical plant tour, and interviews with staff. LPA requested the following documents: Resident Roster, Staff Roster/Schedule, Physicians Report for previous resident, Hospice Care Plan, Medication Administration Records (MAR) for May – August 2021, requested documents were received on 09/13/2021
Cont on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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-20210902125751

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: AYRES RESIDENTIAL CARE HOME-CENTURY CITY	FACILITY NUMBER: 197602934
	VISIT DATE: 05/12/2022

NARRATIVE

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On 05/12/2022, LPA Agard delivered findings.

Regarding the allegation: Staff did not follow physician's orders for administration of medication(s). “It’s being alleged a person with needs, staying at the board and care home was either over medicated or undermedicated.” The investigation revealed the following: 2 out of 2 staff denied the allegation to be true. S1 states, “all the medication on the medication administration records was being given. Everything that was on the med sheet was given.” S2 states, “we have always given medications for R1 as prescribed. The private caregiver was using a medication that was not prescribed by Hospice and they wanted us to use that same medication without an order.”

LPA was unable to conduct interviews with residents due to their cognitive abilities. During interviews with witnesses, W1 states being told medication was not being given as prescribed. “A late-night person at the facility told me and W3 that they were not giving R1 morning medication. W2 could not confirm the allegation to be true but cites: “I recall a conversation with S2 regarding issues with the medication. We provided the facility with a list of medications to give the patient but there are some cases where the family have their own preferences of medication which happened in this case. They will bring their own over the counter meds and creams that they want to use but we wouldn’t know about it.” W3 was unable to confirm or deny the allegation and W4 states never having an issue or concerns about medication with the facility.

LPA Agard reviewed the medication administration records (MAR) which indicate R1’s medication was given as prescribed. LPA was unable to verify which medication was allegedly being overmedicated or undermedicated by reporting party.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. 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, and a copy of the report was given

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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