197607966-9-29-2021-11-AS-AJKK-C7ZLVN-20211021090548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607966
Report Date: 09/29/2021
Date Signed: 09/29/2021 01:41:16 PM

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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/20/2021 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210920162220

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:	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:	Denise Davenport, Chief Domiciliary Services		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Illegal Eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation for the allegation listed above. LPA met with Chief, Domiciliary Services, Denise Davenport and explained the purpose of this visit is to gather information regarding the complaint allegation.

On 09/29/2021 LPA Agard toured the facility grounds for the main building of the Residential Care Facility for the Elderly (RCFE) and requested copies of the following: 1) a copy of the client roster, 2) Any Incident reports from the past 90 days, 3) Any eviction notifications. Requested documents were received at the time of visit.

On 09/29/2021, LPA Agard delivered findings.

Regarding the allegation: Illegal eviction. It’s being alleged that a client in care was illegally evicted,
Continues on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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-20210920162220

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
MONTEREY PARK, CA 91754

FACILITY NAME: VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES	FACILITY NUMBER: 197607966
	VISIT DATE: 09/29/2021

NARRATIVE

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transferred to the skilled nursing facility (SNF) due to their inability to eat independently, and did not received their belongings.

The investigation revealed the following: In the interview with R1 it was revealed that “everything has been resolved and there is no need for you (LPA) to visit the facility.” In an interview with Denise Davenport, Chief Domiciliary Services, it was revealed there have been no evictions within the past 90 days. She states R1 was moved to a SNF due to resident having a fall and the need for rehabilitation. Davenport states resident was never separated from their belongings, was on a “bed hold” and was scheduled to return to the RCFE once rehabilitation was completed. She states resident had access to their belongings for the duration of their stay within the SNF and would “come back and forth to bring things over.” She states while resident was in the care of the SNF it was discovered that the resident was displaying signs of having difficulties eating independently. Per record review, resident was evaluated on 06/08/2021, and monitored until they were cleared to return to the RCFE on 09/27/2021.

During a record review, LPA observed a supporting incident report was submitted by the facility stating that the resident had a fall while in the community on 04/25/2021 which resulted in R1 dislocating and fracturing their right shoulder and the requirement for rehabilitation.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. 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.

Exit interview conducted, and a copy of the report was given to Denise Davenport, Chief Domiciliary Services

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

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