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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602934
Report Date: 10/17/2024
Date Signed: 11/22/2024 10:38:00 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2024 and conducted by Evaluator Sparkle Day
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240320160727
FACILITY NAME:AYRES RESIDENTIAL CARE HOME-CENTURY CITYFACILITY NUMBER:
197602934
ADMINISTRATOR:MICHAEL GABAIFACILITY TYPE:
740
ADDRESS:10363 CALVIN AVETELEPHONE:
(310) 475-6484
CITY:LOS ANGELESSTATE: CAZIP CODE:
90025
CAPACITY:6CENSUS: 6DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Michael GabaiTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
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9
Questinable Death
Staff did not ensure care plan was followed for resident
Staff does not ensure facility has a 3 days of perishable food for residents in care
Staff does not ensure reporting requirements are followed
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
8
9
10
11
12
13
This report serves as an amendement to the 10/17/24 report. The complaint findings reflected from 10/17/24 report remain the same. LPA soley inputted R#1 cause of death.
On10/17/2024 Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced subsequent complaint visit .LPA Day met with Administrator, Michael Gabai and explained the purpose of today’s visit.

The investigation consisted of the following: During todays visit LPA Day along with the Administrator toured the facility and observed the food supply both perishable and non pershiable . Today LPA Day interviewed 3 of 3 (S1-S3) staff, 2 of 6 residents (R2-R3) and contacted Skirball Hospice Agency (W1). On 3/22/24 LPA Mario Leon toured the facility with the Administrator. LPA DeLeon requested resident roster, staff roster,Resident #1's service records (Admission Agreement, Appraisal, Physician's Report, Doctor's/Hospital records, medication chart, Hospice sign in sheet, nurses notes and death certificate . LPA received Staff Reporting trainings, First Aid certificates and other pertinent records. LPA Leon interviewed three staff (S1-S3).
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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 2
Control Number 11-AS-20240320160727
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: AYRES RESIDENTIAL CARE HOME-CENTURY CITY
FACILITY NUMBER: 197602934
VISIT DATE: 10/17/2024
NARRATIVE
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32
ALLEGATION: QUESTIONABLE DEATH

It is alleged that resident #1s (R1) death is questionable due to care at the facility. On 10/17/24 from 11:10am - 11:35 am LPA Day interviewed S1- S3 , 3 of 3 staff deny the allegation. LPA Day reviewed the Death certificate of R#1 and spoke with R#1s Hospice Agency (Skirball Hospice Agency) (W1) who ensured that they had no concerns with the facility care for R#1. On 3/22/24 LPA Mario Leon interviewed S1-S3 , 3 of 3 staff who deny the allegation .LPA Day reviewed R#1 death certificate which indicates the death was due to Cardiopulmonary Arrest with Myelodysplastic Syndrome. Based on information gathered including records review, interviews , physician’s report and death certificate there is no sufficient evidence to corroborate the above allegation. Therefore the LPA finds this allegation to be UNSUBSTANTIATED.

ALLEGATION: STAFF DID NOT ENSURE CARE PLAN WAS FOLLOWED FOR RESIDENT

It is alleged that the facility staff did not follow the care plan for Resident #1 (R1).On 10/17/24 from 11:10am - 11:35 am LPA Day interviewed S1- S3 , 3 of 3 staff deny the allegation. On 3/22/24 LPA Mario Leon interviewed S1-S3 , 3 of 3 staff deny the allegation . All staff interviewed were consistent with their statements that R#1 was checked on and rotated every 2 hours. On 10/17/2024 LPA Day spoke with Skirball Hospice Agency (W1) who visited the facility every 2 days and ensured that they had no concerns with the facility care for R#1. LPA Day reviewed staff roster and ensured the staffing is within Title 22 guidelines. Based on information gathered including records review, interviews , physician’s report there is no sufficient evidence to corroborate the above allegation. Therefore the LPA finds this allegation to be UNSUBSTANTIATED.

ALLEGATION: STAFF DOES NOT ENSURE FACILITY HAS A 3 DAY OF PERISHABLE FOOD FOR RESIDENTS IN CARE

It is alleged that the facility does not ensure that there is 3 days of perishable food for the residents in care On 10/17/24 from 11:10am - 11:35 am LPA Day interviewed S1- S3 , 3 of 3 staff deny the allegation. Staff were consistent with their statements that food is purchased every 2 weeks and there is always enough food . LPA Day interviewed R2-R3 who were consistent in their statements that there is always plenty of food During todays visit (10/17/24) LPA Day toured the facility and observed the food supply both perishable and non perishable and found that the food supply was adequate at time of visit. Based on the information gathered, interviews conducted and the observation of the LPA there is no sufficient evidence to corroborate the above allegation. Therefore the LPA finds this allegation to be UNSUBSTANTIATED.

ALLEGATION: STAFF DOES NOT ENSURE REPORTING REQUIREMENTS ARE FOLLOWED

It is alleged that the facility staff does not ensure reporting requirements are followed. On 10/17/24 from 11:10am - 11:35 am LPA Day interviewed S1- S3 , 3 of 3 staff deny the allegation. Staff were consistent with their statements that all unusual incidents are reported to Licensing, doctors and family members. LPA Day reviewed trainings of all staff of which including reporting requirements. LPA reviewed previous incident reports in file. Based on the information gathered and the observation of the LPA there is no sufficient evidence to corroborate the above allegation. Therefore the LPA finds this allegation to be UNSUBSTANTIATED.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2