197603601-10-21-2024-11-AS-EMAZ-DATRWD-20241108122258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603601
Report Date: 10/21/2024
Date Signed: 10/21/2024 01:22:07 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, 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
12/21/2023 and conducted by Evaluator Alfonso Iniguez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231221160832

FACILITY NAME:	BEVERLY HILLS LOVING CARE		FACILITY NUMBER:	197603601
ADMINISTRATOR:	LIDA ZARAFSHAN		FACILITY TYPE:	740
ADDRESS:	1019 S. WOOSTER STREET		TELEPHONE:	(310) 652-3555
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	176	CENSUS: 74	DATE:	10/21/2024
		UNANNOUNCED	TIME BEGAN:	10:09 AM
MET WITH:	Lida Zarafshan/Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff neglect/lack of supervision resulted in a resident sustaining a serious injury.
Facility ramp is unsafe causing resident to fall.
Staff did not respond to resident's request for assistance as needed.

INVESTIGATION FINDINGS:

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On 10/21/2024 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Lida Zarafshan/Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: Investigations Branch (IB) referral accepted dated 12/12/23 and completed investigation on 8/22/24. CCLD staff conducted the following interviews: Administrator Interview (A#1) 1/11/24, Facility Staff 1 Interview (S#1) 1/11/24, Witness Interview 1 (W#1) 1/31/24, Resident 1 Interview (R#1) 3/15/24, Witness Interview 2 (W#2) 4/15/24, Resident 2 Interview (R#2) 5/23/24, Resident 3 Interview (R#3) 5/23/24, Resident 4 Interview (R#4) 5/23/24, Resident 5 Interview (R#5) 5/23/24, Resident 6 Interview (R#6) 5/23/24, Facility Staff 2 Interview (S#2) 5/23/24, Facility Staff 3 Interview (S#3) 6/18/24. CCLD staff gathered the following documents: (R#1)’s Resident Appraisal/Needs and Services Plan dated 6/16/21, (R#1)’s Unusual Incident Reports dated: 10/28/2019, 11/21/2019, 02/24/2020, 04/18/2022, 05/18/2022 and 10/6/2023 and (R#1)’s medical records from Cedar Sinai Hospital dated 2/14/24. On 10/21/2024, the department interviewed the facility administrator (A#1), facility staff (S#1-S#5), residents (R#7-R#13) and conducted a health and safety check.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

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 4

Control Number 11-AS-20231221160832

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: BEVERLY HILLS LOVING CARE	FACILITY NUMBER: 197603601
	VISIT DATE: 10/21/2024

NARRATIVE

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Investigation Revealed the Following:

Allegation: Staff neglect/lack of supervision resulted in a resident sustaining a serious injury.

The details of the complaint alleged that (R#1) sustained a serious injury due to staff neglect/lack of supervision.

During records review gathered by CCLD staff, LPA Iniguez observed that on (R#1)’s Resident Appraisal/Needs and Services Plan dated 6/16/21, there was no indication of a fall risk or prior falls. In addition, (2) out of (5) Unusual Incident Reports from facility regarding (R#1), are related to falls. Moreover, LPA Iniguez observed (R#1)’s medical report from Cedar Sinai Hospital dated 2/14/24. Hospital records does not state that (R#1) has a history of falls. Also, the department reviewed (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly or LIC 602A dated 7/14/22, it is marked that (R#1) is ambulatory and can independently transfer to and from bed.

During an interview conducted by CCLD staff with facility administrator (A#1) on 1/11/24, she stated that on 10/4/23 the facility was hosting a party, (R#1) informed the facility staff that they did not want to attend the party. (A#1) stated that later that day, (R#1) changed their mind and decided they wanted to attend the party, (R#1) made the decision to walk using their walker unassisted from their room towards where the party was held.

During an interview conducted by CCLD staff with facility staff (S#1-S#3), (3) out of (3) stated that (R#1) did not wanted to go to the party but, later they changed their mind and decided to walk with their walker without telling the facility staff. In addition, (3) out of (3) facility staff stated that they are always assisting residents in care.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20231221160832

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: BEVERLY HILLS LOVING CARE	FACILITY NUMBER: 197603601
	VISIT DATE: 10/21/2024

NARRATIVE

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During an interview conducted by CCLD staff with resident 1 (R#1), (R#1) was not able to answer (IB) investigator questions due to cognitive impairment.

During an interview conducted by CCLD staff with residents (R#2-R#6), (5) out of (6) stated that facility staff are always attentive and checking on them frequently.

During an interview conducted by CCLD staff with (R#1)’s Primary physician (W#2), (IB) investigator asked him “if he had ever stipulated an updated in (R#1)’s care plan regarding them able to walk unassisted, (W#2) stated “no to his knowledge”.

Allegation: Facility ramp is unsafe causing resident to fall.

The details of the complaint alleged that (R#1) sustained a serious injury due to facility ramp is unsafe.

During a physical tour of the facility, the department observed that the facility ramp was built from cement and seemed sturdy. Also, the department observed metal railings on both sides of the ramp and an anti-slippery mat where the ramp is.

During an interview with the facility administrator (A#1), she stated, "Yes, the ramp is safe for the residents; it has railings on both sides to help residents grab an anti-slippery mat."

During an interview with facility staff (S#1-S#5), (5) out of (5) stated that the facility ramp is safe for the residents to use.

During an interview with residents (R#7-R#14), (7) out of (7) stated that the facility ramp is safe to use.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20231221160832

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: BEVERLY HILLS LOVING CARE	FACILITY NUMBER: 197603601
	VISIT DATE: 10/21/2024

NARRATIVE

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Allegation: Staff did not respond to resident's request for assistance as needed.

The details of the complaint alleged that facility staff does not respond to resident’s request for assistance.

During an interview with the facility administrator (A#1), she stated that yes, the facility staff responded to the resident’s request immediately, in less than 5 minutes. There’s always an extra caregiver to assist with the call light when the resident requests assistance.

During an interview with facility staff (S#1-S#5), (5) out of (5) stated that they do assist the residents promptly; it takes them less than 5 minutes to help them.

During an interview with residents (R#7-R#14), (7) out of (7) stated that the facility staff assisted them in a timely manner, and it took them less than 5 minutes.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the Complaint Report was given to Lida Zarafshan /Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC9099 (FAS) - (06/04)

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