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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607136
Report Date: 04/29/2021
Date Signed: 05/02/2021 10:51:49 AM



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
04/09/2021 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210409093730
FACILITY NAME:FOREVER YOUNGFACILITY NUMBER:
197607136
ADMINISTRATOR:MARTINIANA LAURETAFACILITY TYPE:
740
ADDRESS:1059 S. WINDSOR BL.TELEPHONE:
(323) 933-5051
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:6CENSUS: 4DATE:
04/29/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Martiniana LauretaTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility staff hit resident
Facility staff handled resident in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez initiated a telephonic subsequent complaint investigation to deliver investigation findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Martiniana Laureta.

The Investigation consisted of the following: On 4/16/20, LPA obtained a copy of the Client Roster and Staff Roster. LPA conducted a telephone interview with Administrator Martiniana Laureta, Resident 2 (R2) and requested copies of Staff and Resident Rosters and the following documents for R1: Physician's Report, Appraisal/Needs and Services Plan, and hospital discharge paperwork. Administrator also provided LPA with R1's family member contact information. On 4/16/20, LPA Gonzalez conducted an interview with R1's family member. On 4/29/21, LPA interviewed R1, Staff 1-3 (S1-3), and attempted to conduct telephone/ video interviews with R3-4 but was unable to interview the residents due to residents' diagnosis of Major Neurocognitive Disorder.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
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-20210409093730
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: FOREVER YOUNG
FACILITY NUMBER: 197607136
VISIT DATE: 04/29/2021
NARRATIVE
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Investigation revealed the following: Regarding allegation, Facility staff hit resident, it is alleged that facility staff have hurt R1 and have punched R1 in their stomach area when R1 has had a Bladder and/or Bowel accident and after such incidents staff subsequently begin to display a change in behavior which make R1 feel scared to the point that they are afraid and plead for forgiveness. Interview conducted with Administrator Martiniana Laureta revealed that facility staff do not hit any of the facility residents. She stated that on 4/5/21, R1 complained of a stomach ache, looked pale and was vomiting. R1 was hospitalized on the same day and had surgery on 4/10/21 due to an Inflamed Gallbladder that had to be removed by surgery. R1 was discharged from the hospital back to the facility on 4/11/21. S1-3 stated that facility staff do not hit any resident in care and have not seen other facility staff hit any facility resident. R1-2 stated that facility staff do not hit residents. Interview with R1 revealed that staff have not hit them. Interview with R1's family member revealed that they love the services that their loved one receives at the facility and stated that facility staff treat the facility residents with love and respect. Family member stated that R1 has lived at the facility for over five years and they are extremely satisfied with the wonderful services their loved one receives at the facility and most of all they love that staff treat the residents as if they are family. Family member also stated that they are well aware of what steps to take if they ever believe or think that their loved one is being mistreated or physically abused. LPA attempted to interview R3-4 but was not able to properly interview residents as they have a diagnosis of Major Neurocognitive Disorder. LPA reviewed Kaiser Hospital discharge documents which consisted of an After Visit summary dated 4/11/21 that gave the patient (R1) care instructions for Acute Cholecystitis, which is an inflammation of the Gallbladder. Hospital Discharge documents additionally provide instructions for General Anesthesia Discharge, which corroborate the facility administrator's report of R1 being hospitalized and then receiving surgery due to an Inflamed Gallbladder. Lastly, LPA reviewed hospital documents stating that one of R1's ongoing conditions is Cholelithiasis (Gallstone). Based on interviews conducted with facility staff, R1 and R1s family member and LPA review of documents, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility staff handled resident in a rough manner, it is alleged that R1 reported that a male and woman staff (Names not given) have applied excessive pressure to R1's bladder and pressed harder when R1 said "it hurts". It is also alleged that the same two facility staff forcefully clean R1 and they have handled R1 in an aggressive manner for example like throwing resident from one side of the bed to the other side on the bed. R1 verbalized how scared they were to return to the facility and stated that they felt scared to disclose to family about the way R1 feels regarding the facility and staff due to it being financially
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210409093730
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: FOREVER YOUNG
FACILITY NUMBER: 197607136
VISIT DATE: 04/29/2021
NARRATIVE
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difficult for family to move R1 to another facility. LPA interviewed R1 who stated that facility staff do not handle them in a rough manner and have never handled them roughly. R1 also stated that staff have not hurt them by applying pressure to their stomach area. R1 stated that they never said anything like that and that they like the facility staff. Interviews with facility administrator and S1-3 revealed that facility staff do not handle residents roughly, deny that they apply excessive pressure to any resident's stomach area and also denied being rough with residents when they provide assistance to residents. Interview with R2 revealed that facility staff are very nice and very caring people and they have never seen staff hurt or be rough with any facility resident. Interview with R1's family member revealed that they love the services that their loved one receives at the facility and stated that facility staff treat the facility residents with love and respect. Family member stated that R1 has lived at the facility for over five years and they are extremely satisfied with the wonderful services their loved one receives at the facility and most of all they love that staff treat the residents as if they are family. Family member also stated that they are well aware of what steps to take if they ever believe or think that their loved one is being mistreated at the facility. LPA attempted to interview R3-4 but was not able to properly interview residents as they have a diagnosis of Major Neurocognitive Disorder. LPA also reviewed hospital discharge documents that state that R1 had an Inflamed Gallbladder, was in extreme pain and had to have surgery. Based on interviews conducted with facility staff, R1-2, R1s family member, and LPA review of documents there was not enough supportive evidence to concur with the reported 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.

Due to measures implemented due to COVID-19, exit interview was conducted with Administrator Martiniana Laureta via telephone. A copy of the report was sent via email for signature. A hard copy with signature is on file.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3