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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607966
Report Date: 03/28/2024
Date Signed: 06/16/2024 09:35:12 AM

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
03/21/2024 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240321143310
FACILITY NAME:VETERANS HOME OF CALIFORNIA - WEST LOS ANGELESFACILITY NUMBER:
197607966
ADMINISTRATOR:TERESA STARKSFACILITY TYPE:
740
ADDRESS:11500 NIMITZ AVENUETELEPHONE:
(424) 832-8200
CITY:LOS ANGELESSTATE: CAZIP CODE:
90049
CAPACITY:84CENSUS: DATE:
03/28/2024
UNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Teresa StarksTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff did not notify residents' physician about changes in residents' condition while in care.
Facility staff intimidated resident while in care.
INVESTIGATION FINDINGS:
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On 03/28/24, at 10:00am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Teresa Starks, Deputy Administrator. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegations mentioned above.

The investigation consisted of the following: LPA investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R11). Resident Roster, Staff Roster, Admission Agreement, Code of Conduct Violations, ID/Emergency Information, & Care Plan Report for R1 were obtained from the facility.

The investigation revealed the following: Allegation #1- Facility staff did not notify residents' physician about changes in residents' condition while in care.

Report continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2024
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-20240321143310
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: VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES
FACILITY NUMBER: 197607966
VISIT DATE: 03/28/2024
NARRATIVE
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The details of the complaint alleged that the facility administrator (S1) did not notify R1’s mental health provider about R1’s change in condition between 08/02/2023 and 12/01/2023. On 03/28/24, from 10:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R11) regarding the allegation. 4 of 4 staff denied the allegation that the Facility staff did not notify residents' physician about changes in residents' condition while in care. Staff (S1-S4) stated that they had no knowledge of changes in R1’s condition because R1 never came to the staff and let them know that R1 was having any issues. S2 stated If R1 had come to us and said R1 was in crisis we would have notified R1’s mental health provider, but R1 did not; R1 never had an acute episode in the facility to my knowledge. S2 stated further that R1 had clinical and mental health issues while R1 was staying here but they were not acute; and during this period, he did not report any to the staff.
LPA interviewed residents R1-R11 about the allegation that Facility staff did not notify residents' physician about changes in residents' condition while in care. 10 of 11 residents denied the allegation and stated that whenever they have a change in their health and well-being, the staff does notify their physician about any changes in their condition. LPA observed in the Care Plan Report notes, dated 07/12/2023, that R1 declined to be evaluated for R1’s annual RCFE medical exam.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff did not notify residents' physician about changes in residents' condition while in care. 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- Facility staff intimidated resident while in care.

The details of the complaint alleged that the administrator (S1) and security staff provoked and created false information against R1 which resulted in R1 having aggressive and suicidal thoughts. On 03/28/24, from 10:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R11) regarding the allegation. 4 of 4 staff denied the allegation that Facility staff intimidated resident while in care. All staff (S1-S4) stated that they have never intimidated or retaliated against R1 while R1 was a resident in care that caused R1 to be in distress. All staff stated further, that R1 was the one that would make staff and residents uncomfortable with R1’s combative and aggressive behavior. S2 stated that R1 was issued several codes of conduct violations for R1’s behavior towards staff and residents; and was involved in several interdisciplinary meetings to bring attention to R1’s behavior but it persisted and didn’t get any better. But at no time did anyone ever intimidate R1. LPA interviewed R1-R11 about the allegation that Facility staff intimidated resident while in care. 10 of 11 residents denied the allegation and stated that they have not had any problems with staff intimidating or making them feel uncomfortable in any way.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240321143310
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: VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES
FACILITY NUMBER: 197607966
VISIT DATE: 03/28/2024
NARRATIVE
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Based on interviews, there is insufficient evidence to support the allegation that the Facility staff intimidated resident while in care. 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 during this visit.

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

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3