197603784-5-16-2023-28-AS-RORN-CSBNX8-20230530105043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603784
Report Date: 05/16/2023
Date Signed: 05/16/2023 04:25:19 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2022 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220419162218

FACILITY NAME:	FAITH MANOR		FACILITY NUMBER:	197603784
ADMINISTRATOR:	CLAREL MARTINE		FACILITY TYPE:	735
ADDRESS:	1832 SOUTH ARLINGTON AVE.		TELEPHONE:	(323) 737-2310
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY:	21	CENSUS: 17	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Clarel Martine		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident's hygiene needs are not being met.
Resident was soiled in feces for a long period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent complaint visit to deliver investigation findings for the above stated allegations. LPA met with Administrator Clarel Martine and explained the reason for the visit.

The investigation consisted of: During the initial visit conducted on 04/28/22, LPA conducted interviews with Administrator Clarel Martine, S1-2 and C2-6. LPA obtained copies of Staff and Client Rosters and Pest Control Invoices for February - April 2022. LPA reviewed C1's facility file and collected copies of documents relevant to the investigation. LPA also condcuted a tour of facility dining room, living room, and five (5) client rooms. LPA attempted to contatct C1's FM. On 5/3/22, LPA conducted a telephone interview with C1 FM. On 2/14/23, LPA mailed/ faxed Investigative Subpoena Duces Tecum to PIH Health Good Samaritan Hospital

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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 5

Control Number 28-AS-20220419162218

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAITH MANOR	FACILITY NUMBER: 197603784
	VISIT DATE: 05/16/2023

NARRATIVE

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requesting copies of hospital records for C1. On 4/6/23, LPA received PIH Health Good Samaritan Hospital hospital records for C1. On 05/16/23, LPA collected copies of Staff and Client Rosters. LPA additionally conducted a tour of facility which included observations of common areas, dining room, living room, and three (3) bathrooms.

The investigation revealed the following: Regarding allegations of Resident's hygiene needs are not being met and Resident was soiled in feces for a long period of time, allegedly C1 was covered in dirt, bed bugs and feces and was incontinent for multiple days, the client's room was unkempt and client was also not able to care for themselves. Interviews with Administrator and facility staff revealed that C1 was not covered in bed bugs dirt or feces. They stated that C1's FM would visit the client regularly and ensured that C1 had everything that they needed and was provided adequate care. Administrator and staff denied that C1 was incontinent for multiple days and they stated that if C1 had feces on their clothing it was most likely only from that day (04/18/22). They stated that C1 was able to take care of themselves, was independent and did not require any assistance with Activities of Daily Living (ADLs). LPA review of C1's PIH Health Good Samaritan Hospital medical records revealed that C1 was hospitalized on 4/18/22 and was minimally responsive when they arrived to the hospital emergency room, and C1's clothing were noted to have been tossed due to having feces and bed bugs. C1 was also noted to have lice. C1 received treatment for lice and the clothing was thrown out by hospital staff. C1 also received other medical treatments. C1 was not interviewed as they passed away on 4/19/22. LPA conducted initial complaint visit on 4/28/22 and observed live bed bugs in two client rooms, LPA cited and issued civil penalties to the facility on 4/28/22 for observation of bed bugs. LPA's observations of three other client rooms revealed that client's rooms were not unkempt at the time of the visit. LPA review of C1's facility file documents revealed that C1 was not incontinent and did not require assistance with their ADLs, but although C1 was not incontinent, and was able to maintain hygiene care, the administrator, and facility staff failed to observe the changes in C1's health and hygiene as they had deteriorated, as hospital records stated that C1's clothing had feces, client had lice and bed bugs on their body at the time they were transported and admitted to the hospital emergency room. Hospital records also indicated that C1 was also minimally responsive when they arrived to the hospital.

Based on interviews conducted with facility staff, and LPA review of medical records, the preponderance of evidence standard has been met, therefore the above stated allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview was conducted with Tompi Sihamu. A copy of the report and appeal rights were provided to facility staff.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20220419162218

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAITH MANOR	FACILITY NUMBER: 197603784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/26/2023 Section Cited CCR 85075.4(a)	1 2 3 4 5 6 7	Observation of the Client The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.	1 2 3 4 5 6 7	Administrator to submit written Plan of Correction which also includes staff training to ensure the facility is meeting Title 22 Regulation. Administrator to submit a faxed or mailed copy of POC with proof of staff training by due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on review of hospital records that indicated that C1 was found minimally responsive when they arrive to the ER and C's clothing had feces, bed bugs and client had lice, which poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
Type B 05/26/2023 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs.	1 2 3 4 5 6 7	Administrator to submit written Plan of Correction which also includes staff training to ensure the facility is meeting Title 22 Regulation. Administrator to submit a faxed or mailed copy of POC with proof of staff training by due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Review of Hospital records indicated that C1's clothing had feces, bed bugs and client had lice,which poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2022 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220419162218

FACILITY NAME:	FAITH MANOR		FACILITY NUMBER:	197603784
ADMINISTRATOR:	CLAREL MARTINE		FACILITY TYPE:	735
ADDRESS:	1832 SOUTH ARLINGTON AVE.		TELEPHONE:	(323) 737-2310
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY:	21	CENSUS: 17	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Clarel Martine		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20220419162218

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAITH MANOR	FACILITY NUMBER: 197603784
	VISIT DATE: 05/16/2023

NARRATIVE

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requesting copies of hospital records for C1. On 4/6/23, LPA received PIH Health Good Samaritan Hospital hospital records for C1. On 05/16/23, LPA collected copies of Staff and Client Rosters. LPA additionally conducted a tour of facility which included observations of common areas, dining room, living room, and three (3) bathrooms.

The investigation revealed the following: Regarding allegation, Resident sustained injuries while in care, it is alleged that C1 had multiple abrasions to their feet and hands. Interviews with Administrator and facility staff revealed that they did not observe C1 to have abrasions to their feet and hands. They stated that C1 was visited by C1 FM and a friend often and they ensured that C1 was well and had everything that they needed. Administrator and staff denied that C1 sustained any injuries at the facility and stated that if anything was noted at the hospital it was self inflicted by C1. They also stated that C1 was independent and went out into the community daily and they are not aware as to what C1 did while out of the facility. Interview with C1 FM revealed that they had visited with C1 recently and they did not observe that C1 had any abrasions or any marks that raised any concerns. C1 FM stated that if C1 was concerned about anything they would have told C1 FM. C1 FM stated that C1 had lived at the facility for over one year and he did not have any concerns and they were satisfied with the services that C1 was receiving. C1 FM stated that C1 had a problem with drug use for many years and they tended to continuously scratch their skin. LPA review of C1's PIH Health Good Samaritan Hospital medical records revealed that C1 was hospitalized on 4/18/22 and was observed to have broken skin from scratching all over body. Skin exam was noted to be normal. Skin exam included findings of skin warm, dry, scattered abrasions/ bug bite marks. Interviews conducted with 5 out of 5 clients revealed that they are satisfied with all services received at facility, interactions with facility staff are respectful at all times, they have not sustained any injuries while at the facility and they did not have any concerns. C1 was not interviewed as they passed away on 4/19/22. LPA also observed interactions between clients and staff and did not observe anything of concern. Based on interviews conducted with facility administrator/ staff, facility clients, and LPAs observations and review of documents there was not enough supportive evidence to concur with the reported allegation.

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.

Exit interview held. A copy of the report was provided to Facility Staff Tompi Sihamau.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

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