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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197605591
Report Date: 09/22/2021
Date Signed: 09/22/2021 04:18:29 PM



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 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
01/07/2020 and conducted by Evaluator Joe Katrdzhyan
COMPLAINT CONTROL NUMBER: 28-AS-20200107153321
FACILITY NAME:WESTMINSTER GARDENSFACILITY NUMBER:
197605591
ADMINISTRATOR:WALPER, MICHAELFACILITY TYPE:
741
ADDRESS:1420 SANTO DOMINGO AVENUETELEPHONE:
(626) 358-2569
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY:200CENSUS: 40DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Staff / Ana Cortez
Sales Coordinator / Erica Cox
Director of Wellness / Eusebio "Sev" Tienda
TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff failed to respond to resident's medical needs resulting in hospitalization

Facility staff failed to follow Physician's orders
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nune Margaryan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegations of "Staff failed to respond to resident's medical needs resulting in hospitalization" and "Facility staff failed to follow Physician's orders". Upon arriving at the facility, LPAs met with Staff / Ana Cortez and Erica Cox and were later joined by Director of Wellness / Eusebio "Sev" Tienda who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 1/16/2020, in reference to the allegations listed above. During the course of the investigation, LPA conducted interviews of various persons to include the Previous Administrator / Michael Walper, Previous Director of Wellness / Martha Cruz, LVN 1, LVN 2 and Resident 1 (R1). LPA made an attempt to interview LVN 3 but was unsuccessful. LPA also reviewed and obtained copies of the following documents in reference to R1;
• Resident Cover Sheet • Identification and Emergency Information Sheet • Discharge Instructions from Royal Oaks Skilled Nursing • Interdisciplinary Notes for period 11/22/19 - 12/6/19 • Physician's Order dated 12/3/19
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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 3
Control Number 28-AS-20200107153321
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WESTMINSTER GARDENS
FACILITY NUMBER: 197605591
VISIT DATE: 09/22/2021
NARRATIVE
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requesting Physical Therapy • Log for Checking on Residents every 2 hours for period 11/22/19 -
12/6/19 • Physician's Report • RCFE Resident Appraisal.

The investigation revealed the following;
Allegation: Staff failed to respond to resident's medical needs resulting in hospitalization. The details of the allegation states that on the evening of 10/18/19, R1's daughter called R1 and based on their conversation she determined that R1 was not in the right state of mind. R1's daughter called the reception desk in Independent Living asking staff to check on R1. According to R1's daughter, staff did not check on R1. The following day, R1's friend came to the facility and found R1 in her bed at 1PM unable to move or speak coherently. R1's friend called 911 and R1 was taken to the hospital.
Based on the interview of LVN 2, LVN 2 could not recall receiving a call from the daughter of R1 asking to check on R1's condition. Staff interviewed stated that residents are checked each time a call is made by family requesting a staff member to check on a resident. Based on the interview of LVN 1, LVN 1 denied having knowledge of R1 not feeling well on 10/19/19. During her shift on 10/19/19, LVN 1 stated that she was surprised to see the paramedics arrive at the facility asking to see R1. LVN 1 escorted paramedics to R1's room finding R1 and R1's friend inside the room. According to LVN 1, R1's friend did not call staff for help and called 911 upon discovering R1 was not feeling her usual self. Based on interviews conducted, LPA learned that staff in Independent Living (IL) have a way of monitoring the IL residents. It's called "keeping an are you okay check" on the residents, which residents have to push the are you okay button (from their rooms) between the hours of 5am – 10am. If a resident fails to push the are you okay button by 10am, the computer generates a list of residents which staff will need to contact ensuring the resident well being. If there is no answer, staff will go in person and check on the resident in their apartment. In the case of R1, R1 had pressed the are you ok button in the morning alerting staff that everything was okay. During the interview of R1, R1 could not recall the incident other than waking up at the hospital on 10/19/19. In reference to her stay at Westminster Gardens, R1 stated that "this is a great place to live, staff Is helpful and the people are wonderful". Based on interviews conducted, there is insufficient evidence to support the allegation of Staff failed to respond to resident's medical needs resulting in hospitalization.

Allegation: Facility staff failed to follow Physician's orders. The details of the allegation states the facility took three weeks to begin physical therapy.
Based on the file review for R1 and interviews conducted, the following information was gathered.
(Please see LIC 9099C for additional information)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200107153321
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WESTMINSTER GARDENS
FACILITY NUMBER: 197605591
VISIT DATE: 09/22/2021
NARRATIVE
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On 10/19/19, at 12:30PM, R1 was hospitalized at Methodist Hospital. On 10/25/19, R1 was transferred to Royal Oaks Skilled Nursing. On 11/22/19, R1 was transferred from Royal Oaks Skilled Nursing to Westminster Gardens Assisted Living, under respite care. On 12/6/19, R1 was discharged from Assisted Living respite care to her Independent Living apartment at Westminster Gardens. After reviewing the discharge instructions dated 11/22/19 from the treating physician, LPA discovered that there was no written order for physical therapy (PT) for R1. On 12/5/19, it is noted that R1 was visited by Concord Home Health and R1 will have a PT evaluation and treatment. Based on interviews conducted and record review, there is insufficient evidence to support that Westminster Gardens failed to follow physician's orders for PT in reference to R1.

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, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3