197607966-9-19-2023-11-AS-MVAO-CW3QNR-20230927121935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607966
Report Date: 09/19/2023
Date Signed: 09/19/2023 01:04:55 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, 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
06/06/2023 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230606142622

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: 60	DATE:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	11:14 AM
MET WITH:	Teresa Starks		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Wrongful eviction.
Staff not providing a safe environment for resident.

INVESTIGATION FINDINGS:

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On 06/14/23, Licensing Program Analyst (LPA), Perry Scott initiated a 10-day complaint investigation at the facility listed above. LPA Scott met with Supervising Registered Nurse, Julius Lozano and explained the purpose of today’s visit was to investigate the allegations listed above.

On 06/14/23, the investigation consisted of the following:

During today's visit LPA conducted a health & safety check of the facility. LPA conducted interviews with the staff (S1- S3), and residents (R1 & R2). LPA requested and obtained copies of the following documents: Resident and staff roster, eviction notice for R1, ID/Emergency information, admission agreement, code of conduct agreement, Interdisciplinary Team meeting note, and eviction procedures.

The investigation revealed the following: Allegation # 1 Wrongful eviction.

Report continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230606142622

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES	FACILITY NUMBER: 197607966
	VISIT DATE: 09/19/2023

NARRATIVE

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On 06/14/23, LPA interviewed S1-S3 about the allegation. It was alleged that R1 punched R2 while having a disagreement at the facility. All staff corroborate that indeed R1 punched R2. LPA conducted an interview with R1 and R2. R1 did not deny that R1 punched R2 in the face while having a disagreement. R2 confirmed that they were arguing and R1 got up and punched R2 in the face.

Upon an investigation of the incident, the facility had an Interdisciplinary Treatment Team meeting to address the issue. The facility maintains in their Resident, Code of Conduct, entitled Abuse/Violence/Illegal Actions that “if the incident involves elder abuse, threats of violence or violence against another resident…the resident may be considered for immediate involuntary discharge from the home”. Accordingly, the facility issued R1 a thirty-day eviction notice that complied with Title 22 regulations.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the facility issued a Wrongful eviction. 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 #2: Staff not providing a safe environment for resident.

On 06/14/23, LPA interviewed S1-S3 about the allegation. All staff reported that no one has ever come to them stating that the staff are not providing a safe environment for the resident. LPA interviewed R1 about the allegation and R1 stated that R2 had been harassing R1 but R1 did not tell anyone about it. LPA interviewed R2 and R2 stated that there haven’t been any problems with R1 in the past.

Based on interviews and records reviewed there is insufficient evidence to support the allegation: Staff not providing a safe environment for resident. 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.

No deficiencies were cited.

An exit interview was conducted, and a hard copy of this report was provided to Deputy Administrator, Teresa Starks.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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