<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607718
Report Date: 03/09/2022
Date Signed: 03/09/2022 02:49:12 PM

Substantiated


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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2022 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20220302160402
FACILITY NAME:CENTINELA ASSISTED LIVING CENTREFACILITY NUMBER:
197607718
ADMINISTRATOR:GWENDOLYN CRAIGFACILITY TYPE:
740
ADDRESS:1000 S FLOWER STTELEPHONE:
(310) 674-3216
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY:96CENSUS: 58DATE:
03/09/2022
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Evelyn Hernandez-Social ServicesTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff administered incorrect medication for a resident while in care
Staff did not meeting a resident's diabetic needs while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/9/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint visit at this facility. LPA spoke with Social Services Elizabeth Hernandez via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to investigate the allegations listed above.

The investigation consisted of the following: On 3/9/2022 LPA conducted a tour of facility grounds and reviewed facility records. LPA conducted interviews with (5) staff members (S1-S4), and (5) residents (R2-R6). LPA Cifuentes requested and received the following documents: Client roster, staff roster, incident reports and other documentation relevant to the investigation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
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 3
Control Number 11-AS-20220302160402
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
MONTERY PARK, CA 91754
FACILITY NAME: CENTINELA ASSISTED LIVING CENTRE
FACILITY NUMBER: 197607718
VISIT DATE: 03/09/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Staff administered incorrect medication for a resident while in care

The complainant alleges that facility gave R1 incorrect dose of insulin. LPA reviewed facility documents, An order was received on 1/10/2022 changing R1’s medication dosages. LPA reviewed medication administration record and noted that for February of 2022, wrong dosage of medication was being administered to resident R1. LPA Cifuentes interviewed residents (R2-R6). R1 was unavailable for interview. Of those interviewed, one stated they took their medication themselves, three stated they had no issues with medications and one was unsure. LPA interviewed staff (S1-S4) regarding resident medications. All four staff stated they had heard of a resident being given incorrect medication.

Based on information gathered, the Department did find sufficient evidence to support the allegation mentioned above.

Allegation: Staff did not meeting a resident's diabetic needs while in care

The complainant alleges that R1 blood sugar was not properly monitored during their time at facility, it should have been checked three times per day. LPA reviewed medication administration record for R1 for month of February, which only shows 6am blood sugar check routinely completed, the check before lunch only occurred 10 times and the check before dinner only occurred twice in the month. LPA spoke with residents (R2-R6) regarding the allegations. R1 was unavailable for interviews. Of those interviewed, two out of five stated they had diabetes, but there were no issues with their insulin. LPA Cifuentes interviewed staff (S1-S4) regarding diabetic residents. S2 stated residents blood sugar is always checked and logged in MAR.

Based on information gathered, the Department did find sufficient evidence to support the allegation mentioned above.

Based on information gathered, the department did find sufficient evidence to support allegations " Staff administered incorrect medication for a resident while in care,” and “Staff did not meeting a resident's diabetic needs while in care.”

Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.



An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Social Services Elizabeth Hernandez
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220302160402
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
MONTERY PARK, CA 91754

FACILITY NAME: CENTINELA ASSISTED LIVING CENTRE
FACILITY NUMBER: 197607718
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2022
Section Cited
CCR
87465(c)(2)
1
2
3
4
5
6
7
Incidental Medical and Dental Care
Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator will conduct staff training regarding medication adminstration for diabetes residents with qualified medical proffesional. Licensee will send CCLD a copy of training outline as well as sign in sheet via fax by POC due date.
8
9
10
11
12
13
14
Based on interviews and record reviews LPA noted that R1's was given the incorrect dosage of their medication. LPA also noted that physician requested blood sugar be noted four times dailly, which was not completed. This violation possesses an immediate Health and Safety risk to residents in care.
8
9
10
11
12
13
14
CCR
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3