197605591-3-8-2024-28-AS-LHIS-D3CLWP-20240314090726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605591
Report Date: 03/08/2024
Date Signed: 03/08/2024 02:10:39 PM

Unsubstantiated

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
08/26/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220826104506

FACILITY NAME:	WESTMINSTER GARDENS		FACILITY NUMBER:	197605591
ADMINISTRATOR:	ANDREW M SMITH		FACILITY TYPE:	741
ADDRESS:	1420 SANTO DOMINGO AVENUE		TELEPHONE:	(626) 358-2569
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	200	CENSUS: 177	DATE:	03/08/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Sev Tienda, Director of Wellness		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Residents are being bullied while in care.
Staff yell at the residents while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit regarding the above allegations. The purpose of the visit was explained to Director of Wellness Sev Tienda.

The investigation consisted of the following: On 9/1/2022, a physical plant tour of the assisted living, memory care unit, dining room, and facility grounds was conducted. Staff (S1-S6) and residents (R1-R4) were interviewed. Resident (R1's) file documents [Profile Face Sheet, Preplacement Appraisal Information, Resident Appraisal (1/25/2022), Physician Report (4/3/2019), MD letter (3/1/22), Advance Healthcare Directive, Power of Attorney, Montreal Cognitive Assessments (MOCA), Notice of CCRC Resident Level of Care Transfer, incident report (1/28/22)] were reviewed and obtained, as well as resident rosters, and LIC 500 Personnel Report. During today's, visit LPA toured the Memory Care Unit, the Assisted Living Unit, and interviewed residents (R5- R10).

***Narrative continues next page.***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

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 28-AS-20220826104506

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: 03/08/2024

NARRATIVE

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Allegation: Residents are being bullied while in care. It is alleged that the sales team staff were bullying residents into considering a move into the Memory Care Unit. Based on interviews conducted, all eight (8) staff denied the allegation and stated that residents are explained the advantages of living in each of the CCRC areas, as well as level of care services and ultimately it is the resident's choice. According to staff interviews, discussion about the possibility of moving into the Memory Care Unit is based on their annual appraisal and any change in condition. Per staff interviews, if there is a change in condition the Care Team meets and a Care conference is held with resident and family member and/or authorized representative to discuss options. In resident (R1's) case, the resident was temporarily placed in the Bridge Care program per family request due to increased weakness. Staff stated the Director of Wellness assessed R1 based on the level of care needed during their stay in the Bridge Care program. At that time, an updated Physician's Report had not been provided to the facility, therefore the facility administered a MOCA assessment and R1's spouse initially agreed to moving the resident in to the Memory Care unit but backed out. One (1) family member was interviewed and reported that the staff team did not bully them into placing their loved one in the Memory Care Unit. A total of 10 residents were interviewed, and only 2 residents said they felt pressured "bullied" about moving their partners into the Memory Care Unit. The department was unable to obtain evidence to support this allegation.

Allegation: Staff yell at the residents while in care. It is alleged that the facility's Sales Representative often screams and yells at residents when approached with questions. A total of eight (8) staff were interviewed of which all denied the allegation. The Sales team staff stated that all residents are treated with dignity and respect and are never yelled at. Sales Representative (S5) stated they do not yell/scream at residents, and that on the contrary residents say to staff the voice tone is too soft spoken. Staff (S5) stated that they do speak in a louder voice tone with hard or hearing residents, and there are some staff that have a naturally louder voice. However, staff stated that they have never yelled at residents (R1 & R2). No staff reported hearing other staff yell at residents. A total of 10 residents were interviewed, of which one (1) resident stated that Sales staff yell at residents. One (1) resident's family member was interviewed and reported no knowledge of the allegation, and stated that they have observed good staff treatment towards residents. There is insufficient evidence to corroborate the allegation.

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 with Wellness Director Sev Tienda and a copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

LIC9099 (FAS) - (06/04)

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