197607966-8-22-2023-11-AS-MVAO-CXDQ6H-20231108105329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607966
Report Date: 08/22/2023
Date Signed: 08/22/2023 05:10:58 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
08/15/2023 and conducted by Evaluator David Espana

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230815144902

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: 61	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Teresa Starks		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Illegal Eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 08/22/2023, at 9:05 AM Licensing Program Analyst (LPA) David España and Licensing Program Manager (LPM) Ulysses Coronel met with Teresa Starks, Administrator and Julius Lozano, Supervising Registered Nurse to conduct a complaint investigation to address the allegations listed above. LPA España and LPM Coronel met with Teresa Starks, Julius Lozano and explained the purpose of this visit.

The investigation consisted of the following: LPA España and LPM Coronel conducted a tour of the facility grounds. LPA España and LPM Coronel interviewed 6 staff, 6 out of 61 residents, and reviewed the following documents: client roster, staff roster, residents R1 and R2's records which includes admission agreements and eviction notices.
The investigation revealed the following: Regarding the allegation: "Illegal Eviction" During record review of the timeline of events indicated in R1's 3-day eviction notice, LPA and LPM did not observe reasons indicating that R1 was engaging in a behavior which poses an immidiate threat to the physical and mental health of himself or others at the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 5

Control Number 11-AS-20230815144902

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: 08/22/2023

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

During record review of resident R2's 60-day eviction notice LPA and LPM did not observe exact statements "as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing."

Based on LPA’s observations, interviews and record reviews, the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. Deficiencies cited under California Code of Regulations, Tittle 22 are being cited please see LIC 9099D.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Administrator Teresa Starks whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20230815144902

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: 08/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/24/2023 Section Cited CCR 87224(b)	1 2 3 4 5 6 7	Eviction Procedures. The licensee may, upon ... prior written approval from the licensing..., evict the resident upon three (3) day...notice to quit. The licensing...may grant approval...upon finding of good cause. ... facility. This requirement was met by:	1 2 3 4 5 6 7	The licensee shall dismiss the eviction notice to resident R1, in writing, and submit a copy of the dismissal by the POC due date of 08/24/2023.
	8 9 10 11 12 13 14	Based on record reviews the licensee failed to indicate good cause that R1 was engaging in a behavior which poses an immidiate threat to the physical and mental health of R1 or others at the facility, this poses a potential health & safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 08/24/2023 Section Cited CCR 87224(d)(1)(D)	1 2 3 4 5 6 7	The... statement...: "In order to evict a resident ... facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If...hearing." This requirement was met by:	1 2 3 4 5 6 7	The licensee shall dismiss the eviction notice to resident R2, in writing, and submit a copy of the dismissal by the POC due date of 08/24/2023.
	8 9 10 11 12 13 14	Based on record reviews the licensee failed to indicate exact statements as specified in Health and Safety Code Section 1569.683(a)(4):, this poses a potential health & safety and personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5