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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607430
Report Date: 07/06/2022
Date Signed: 07/06/2022 02:33:02 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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2022 and conducted by Evaluator Troy Agard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220413090236
FACILITY NAME:COMFORT HOME FOR ELDERLYFACILITY NUMBER:
197607430
ADMINISTRATOR:SOCORRO TRINIDADFACILITY TYPE:
740
ADDRESS:2729 WESTWOOD BLVD.TELEPHONE:
(310) 470-7302
CITY:WESTWOODSTATE: CAZIP CODE:
90064
CAPACITY:6CENSUS: 4DATE:
07/06/2022
UNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Socorro TrindadTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident sustained a death while in care
Uncleared adult is providing care and supervision
INVESTIGATION FINDINGS:
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On 07/06/2022 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegations. LPA Agard was met with Administrator, Socorro Trindad and explained the purpose of the visit was to gather information regarding this complaint.

The investigation consisted of the following: on 04/14/2022 LPA conducted an initial 24-hour visit inspection, toured the facility, and conducted interviews. LPA requested the following records: Staff and resident roster, death reports from the past 6 months. Due to the need to analyze additional documents, this complaint needed further investigation.


On 07/06/2022, LPA Agard delivered findings.

Continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
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 2
Control Number 11-AS-20220413090236
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COMFORT HOME FOR ELDERLY
FACILITY NUMBER: 197607430
VISIT DATE: 07/06/2022
NARRATIVE
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Regarding the allegation: Resident sustained a death while in care. It's being alleged that a resident passed away due to being neglected. The investigation revealed the following: S1 states, R1 did not pass away at the facility. R1 was transported to the hospital on 03/14/2019 and never returned. S2 denies knowing R1. LPA was unable to make contact with W1. LPA was unable to interview residents R2-5 due to communication barriers. R1 was unavailable to be interviewed.

Regarding the allegation: Uncleared adult is providing care and supervision. Its being alleged that an LVN was not associated to the facility and was providing care and supervision. The investigation revealed the following: S1 states, W1 was not associated because they worked in the capacity of a home health worker. “W1 didn’t work for me, they worked with another company as a home health worker for Enhanced Care Home Health.” S2 denied knowing W1. LPA was unable to make contact with W1. LPA was unable to interview residents R2-5 due to communication barriers. R1 was unavailable to be interviewed.

During an interview with complainant, limited information regarding the name and/or date of birth of resident in question was provided. Complainant stated their intentions was to make an inquiry rather than a complaint. Complainant confirmed alleged perpetrator to be a third-party vendor and not an employee of the facility. During an internal roster review on 04/14/2022, W1 was never associated to the facility as a staff. LPA attempted to contact W2 & W3 to confirm placement of death but was unable to make contact.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations 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 report was given
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2