197603601-1-11-2024-11-AS-SCIS-D2P4HR-20240221180730

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603601
Report Date: 01/11/2024
Date Signed: 01/11/2024 09:46:54 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
12/28/2023 and conducted by Evaluator Felisa Shirley

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231228141222

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:	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Lida Zarafshan, Director		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff forged resident's documents

INVESTIGATION FINDINGS:

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On 1/11/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Director, Lida Zarafshan, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility.

The investigation consisted of the following:

On 1/5/24 LPA reviewed resident files and toured the facility. LPA reviewed and requested copies of the following records: Resident Roster, Staff Roster, resident files and payment standards for requested residents.

The investigation revealed the following:

Cont'd 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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-20231228141222

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: 01/11/2024

NARRATIVE

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Allegation: Staff forged resident’s documents

It is alleged that R-1 was asked to sign a document that they believe did not belong to them as all the information on the document was incorrect. On 1/5/24 LPA Shirley reviewed resident files. During file review, found there to be no evidence of forged documents. LPA did not find a description of a document that R-1 claims they were requested to sign. LPA described said document to the director at the facility and director does not recall any such document. LPA verified SSA# on file with R-1. Resident answered with the correct number. LPA verified address on file with R-1 and resident was confused about which side of the facility she lived on, as this facility uses two mailing addresses. The address assigned is determined by the location of your room. On 1/5/24 LPA conducted interviews with both staff and residents. LPA interviewed staff, staff 1 – staff 7 (S-1 – S-7). LPA asked staff, “Do you forge resident’s document.” Of those interviewed 7 out of 7 stated no. LPA interviewed residents 1 – resident 7 (R-1 – R-7). LPA asked residents, if they believe that staff has forged their documentation. Of those interviewed, 6 out of 7 answered, no.

Based on information gathered, the department did not find sufficient evidence to support allegations "Staff forged resident’s documents.” 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 LIC 9099 was provided to Director Lida Zarafshan.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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