197607966-5-25-2023-11-AS-JHAD-CV7QG7-20230830120902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607966
Report Date: 05/25/2023
Date Signed: 05/25/2023 12:16:53 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
10/25/2022 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221025163930

FACILITY NAME:	VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES		FACILITY NUMBER:	197607966
ADMINISTRATOR:	JULIAN MANALO		FACILITY TYPE:	740
ADDRESS:	11500 NIMITZ AVENUE		TELEPHONE:	(424) 832-8200
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90049
CAPACITY:	84	CENSUS: 57	DATE:	05/25/2023
		UNANNOUNCED	TIME BEGAN:	11:11 AM
MET WITH:	Teresa Starks		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Resident's have access to sharp objects.

INVESTIGATION FINDINGS:

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On 05/25/23 Licensing Program Analyst (LPA) Perry Scott conducted a continuation complaint investigation for the allegation listed above, that was initially conducted on 11/01/2022 by LPA Troy Agard. LPA met with Teresa Starks, Deputy Administrator, and explained the purpose of this visit is to deliver findings.

The investigation consisted of the following:

On 11/01/2022 LPA Agard toured the facility grounds for the main building of the Residential Care Facility for the Elderly (RCFE). The RCFE facility consists of 2 floors, including 34 double rooms and 16 single rooms, a total of 50 bathrooms, a bathing room, barbershop, activity room, dining room, 4 dens and a kitchen. LPA interviewed staff, residents, a witness, and reviewed records. LPA Agard requested documents, which were received at the time of visit.

The investigation revealed the following: Regarding allegation #1: Residents have access to sharp objects.

It’s being alleged that a resident had access to and pulled a pair of scissors on another resident. LPA Agard attempted interviews with 8 out of 57 residents. 0 out of 7 were able to confirm the allegation. 1 resident was unavailable for an interview. R1 states, “I never saw that, I heard about it from people talking about it. That’s what I heard.” R2 states, “the facility doesn’t allow us to have access to sharp items.”

Report continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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 4

Control Number 11-AS-20221025163930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES	FACILITY NUMBER: 197607966
	VISIT DATE: 05/25/2023

NARRATIVE

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R3 states, “in the dining room we have butter knives but something like a pocketknife they take away from you once you move in or at least they did when I moved in.” R5 states, “I know we are not supposed to have sharp objects, so I don’t know about that.” R6 states, “nope don’t know anything about it.” R7 states, “I don’t know what you are talking about, and I don’t know anything about that allegation.” R8 was unavailable for an interview.
During interviews with staff, LPA Agard interviewed 3 out of 20 staff and 1 witness. 4 out of 4 confirmed the allegation. S1 states, “I think that happened in the resident’s common area in front of the nursing station. R7 grabbed some scissors from the nurse’s station. There was a CNA present during that time and was able to secure it away from them. The scissors were a simple scissor used for cutting paper. It was not sharp.” S2 states, “The resident R7 pulled a scissor on R8. The two of them were arguing and R7 picked up the scissors. I wasn’t present so I’m going off the incident report. I believe there was a code of conduct given to R7. I didn’t witness where the scissors came from but at any given time the nursing station could have tape, scissors, pens, or a stapler which could all be used as a form of a weapon, but residents don’t have access to sharp objects.” S3 states, “this was during a time we were shut down due to Covid.

R7 was eating in the common area and because that was not allowed at the time, I reminded them to put on a mask. R7 yelled at me and R8 heard them yelling and told them not to talk to me like that and to put on a mask. They both started getting into a verbal altercation. R7 was walking towards the nursing station, went behind the desk and grab the scissors out the desk draw. I grabbed the phone and started to call security. R7 started to gesture that he was going to stab R8 and that’s when the Certified Nursing Assistant (CNA), took the scissors out of R7’s hands. They were not even close to R8. The scissors were not sharp enough to be used as a weapon. The residents are not allowed to have anything sharp like that on the premises. During an interview with a witness, W1 states, R7 and R8 got into some form of a disagreement. R7 secured some scissors from the front desk and brandished them towards R8. It was reported as an incident to the California Highway Patrol (CHP), management, and Community Care Licensing. They had a disagreement, or something was said. R7 received a code of conduct from the facility. However, residents don’t typically have access to sharp items."

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20221025163930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES	FACILITY NUMBER: 197607966
	VISIT DATE: 05/25/2023

NARRATIVE

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During a record review, LPA Agard reviewed an incident report and a SOC 341 dated for 01/15/2022 that was sent to licensing self-reporting an incident that took place on 01/15/2022 involving R7’s role in the incident mentioned above. LPA reviewed a code of conduct violations report dated for 02/08/2022 that was issued to R7 for violating the facility rules of threatening other residents and or staff in response to the same incident. During a tour of the facility, LPA observed the alleged scissors that were used on the incident. LPA observed the scissors not to be sharp in shape and removed from nursing station. LPA did not observe any other sharp items to be accessible.

Regarding the allegation… Residents have access to sharp objects, based on LPA’s observation, interviews conducted, and record review, the “preponderance of the evidence” standard has been met; therefore, this allegation is substantiated. Title 22 Division 6 Chapter 8 Article 8 is being cited (please see LIC9099D.)

An exit interview was conducted and a copy of this report and appeal rights were given to Teresa Starks, Deputy Administrator.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20221025163930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES	FACILITY NUMBER: 197607966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/01/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights… (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee shall ensure that all sharp objects are always stored in a locked area in accessible to clients. Licensee immediately removed the sharp object from the resident and placed it in a locked cabinet. Deficiency Cleared at the time of visit.
	8 9 10 11 12 13 14	Based on interviews and records reviewed by LPA Agard, Licensee failed to ensure sharp objects were locked at all times. This violation possess a Health and Safety risk to residents in care.	8 9 10 11 12 13 14
	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.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC9099 (FAS) - (06/04)

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