197607966-3-16-2022-11-AS-AJKK-CD5KX6-20220403081702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607966
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:12:50 AM

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
03/08/2022 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220308140115

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: 58	DATE:	03/16/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Keith Gaines, Resident Care Specialist		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff cut residents hair/beard with residents consent.
Staff does not maintain residents hygiene.
Bathroom door is in disrepair.
Facility failed to safeguard resident’s property.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Keith Gaines, Resident Care Specialist. The purpose of this visit was explained.

LPA Agard conducted an interview with Keith Gaines, Resident Care Specialist of the Residential Care Facility for the Elderly (RCFE). Upon record review and interview, the following was determined: Resident Care Specialist stated, R1 is not a resident of the RCFE. The investigation consisted of the following: During today’s visit, LPA reviewed facility resident roster and found that R1 is not a resident at the RCFE. LPA confirmed that R1 is currently residing in the adjacent building which is the Skilled Nursing Facility (SNF). LPA obtained a copy of the roster from the SNF and from the RCFE. In a review of the staff roster, it was determined the Nursing Supervisor is not a match with the Nursing Supervisor for the RCFE.

Continued on 9099

Unfounded

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: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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-20220308140115

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: 03/16/2022

NARRATIVE

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Community Care Licensing has investigated the complaint alleging: 1) Staff cut residents hair/beard without resident’s consent. 2) Staff does not maintain resident’s hygiene. 3) Bathroom door is in disrepair. 4) Facility failed to safeguard resident’s property. We have found this complaint to be unfounded, meaning that the allegations were false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

No deficiencies were observed/cited during today's visit.

An exit interview was conducted, and a hard copy was provided.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC9099 (FAS) - (06/04)

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