197607430-10-25-2024-11-AS-SCIS-DB3276-20241115160812

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607430
Report Date: 10/25/2024
Date Signed: 10/25/2024 12:26:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2024 and conducted by Evaluator Troy Watson

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240708130938

FACILITY NAME:	COMFORT HOME FOR ELDERLY		FACILITY NUMBER:	197607430
ADMINISTRATOR:	SOCORRO TRINIDAD		FACILITY TYPE:	740
ADDRESS:	2729 WESTWOOD BLVD.		TELEPHONE:	(310) 470-7302
CITY:	WESTWOOD	STATE: CA	ZIP CODE:	90064
CAPACITY:	6	CENSUS: 5	DATE:	10/25/2024
		UNANNOUNCED	TIME BEGAN:	12:21 PM
MET WITH:	Maria Rodriguez - Care Giver - DSP		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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1.Staff did not administer resident's medication as prescribed
2.Staff did not inform the resident's authorized representatives of the resident's change in health condition

INVESTIGATION FINDINGS:

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On 10/25/2024 the Department conducted a subsequent complaint visit to the facility to deliver findings for the allegations listed above. The Department was met by Socorro Trinidad, Administrator and the purpose of today’s visit was explained. The Department was granted access and allowed to enter the facility to conduct the inspection.

Investigation consisted of the following:

CONTINUE TO LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

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 11-AS-20240708130938

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: COMFORT HOME FOR ELDERLY	FACILITY NUMBER: 197607430
	VISIT DATE: 10/25/2024

NARRATIVE

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On 07/18/2024 the Department interviewed Staff #1- Staff# 3 (S1-S3), and reviewed records of resident #1- resident #3 (R1-R3). On 07/18/2024 the Department interviewed witness #1 (W1). The Department requested to the following documents: the Medication Administration Records (MARs), physician's orders of prescriptions, progress notes, health assessments, and any documentation of changes in health condition and incident reports related to Resident #1- Resident #3 (R1-R3). The department requested any communication logs or records, facility's policies and procedures related to medication administration, and training records for S1-S3.

Investigation Revealed the Following:

Allegation: Staff did not administer resident's medication as prescribed
It is alleged that on 7/8/2024 R1 did not receive their PRN medication. On 07/18/2024 the department interviewed Socorro Trinidad, facility administrator. The department asked if staff did not administer resident's medication as prescribed. The Administrator stated there were no concerns or issues with staff administering resident's medication as prescribed. On 07/18/2024 the department interviewed staff #1- staff #3 (S1-S3) who were asked if staff did not administer resident's medication as prescribed. Of those interviewed S1-S3 stated there were no concerns about staff administering resident's medication as prescribed. On 07/18/2024 the department interviewed witness #1 (W1), who was asked if staff did not administer resident's medication as prescribed. Witness #1 (W1) stated there were no concerns about staff administering resident's medication as prescribed.

On 07/18/2024 and 10/22/2024 the department conducted reviews of facility records. Per physicians’ orders from Roze Hospice, R1 was prescribed Morphine Sulfate (Concentrate) to be administered orally at a dose of 5 MG every 4 hours as needed for severe pain or shortness of breath. On 07/18/2024 and 10/22/2024 the department reviewed facility notes, which state a discontinuation of previous medication orders for morphine to be started on 7/7/2024, orders given o the facility at 12:45pm and an accompanying prescription issued on 7/8/2024 written at 12:49PM.

CONTINUE REPORT TO LIC9099C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240708130938

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: COMFORT HOME FOR ELDERLY	FACILITY NUMBER: 197607430
	VISIT DATE: 10/25/2024

NARRATIVE

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Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not administer resident's medication as prescribed. 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.

Allegation: Staff did not inform the resident's authorized representatives of the resident's change in health condition

On 07/18/2024 the department interviewed Socorro Trinidad, Administrator who was asked if staff did not inform the resident's authorized representatives of the resident's change in health condition. The Administrator stated there were no concerns or issues with staff not informing the resident's authorized representatives of the resident's change in health condition. On 07/18/2024 the department interviewed staff #1- staff #3 (S1-S3) who was asked if staff did not inform the resident's authorized representatives of the resident's change in health condition. Of those interviewed S1-S3 stated there were no concerns about staff did not informing the resident's authorized representatives of the resident's change in health condition. On 07/18/2024 the Department interviewed witness #1 (W1) who verified W1 is to be contacted for resident. W1 reported the facility staff provided updates and condition changes of resident’s condition to the authorized representative. On 10/22/2024 the department reviewed facility records and confirmed authorized representative for residents.

Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not inform the resident's authorized representatives of the resident's change in health condition. 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.
There were deficiencies cited on today's visit.

Exit interview conducted. A copy of the report was given to Socorro Trinidad, Administrator.

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SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

LIC9099 (FAS) - (06/04)

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