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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607966
Report Date: 10/24/2022
Date Signed: 10/24/2022 04:20:37 PM

Substantiated


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
10/19/2022 and conducted by Evaluator Troy Agard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221019121217
FACILITY NAME:VETERANS HOME OF CALIFORNIA - WEST LOS ANGELESFACILITY NUMBER:
197607966
ADMINISTRATOR:JULIAN MANALOFACILITY TYPE:
740
ADDRESS:11500 NIMITZ AVENUETELEPHONE:
(424) 832-8200
CITY:LOS ANGELESSTATE: CAZIP CODE:
90049
CAPACITY:84CENSUS: 59DATE:
10/24/2022
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Denise Davenport, Chief, Domiciliary ServicesTIME COMPLETED:
03:56 PM
ALLEGATION(S):
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Staff did not prevent a resident from making inappropriate comments towards other residents
INVESTIGATION FINDINGS:
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On 10/24/2022 Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation for the allegation listed above. LPA met with Denise Davenport, Chief, Domiciliary Services, and explained the purpose of this visit is to gather information regarding the complaint allegation.

On 10/24/2022 LPA Agard toured the facility grounds for the main building of the Residential Care Facility for the Elderly (RCFE). The RCFE facility consists of 2 floors, including 34 double rooms and 16 single rooms, a total of 50 bathrooms, a bathing room, barbershop, activity room, meditation room, dining room, 4 dens and a kitchen. LPA interviewed staff, residents, witnesses and reviewed records. LPA Agard requested the following documents, which were received at the time of visit: 1) a copy of the resident roster, 2) copy of the staff roster, 3) R3 and R4’s physician report, and 4) Any violation(s) of code of conduct for R3 and R4.

On 10/24/2022 LPA delivered findings.
Cont. on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
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-20221019121217
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: 10/24/2022
NARRATIVE
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The investigation revealed the following…Regarding the allegation: Staff did not prevent a resident from making inappropriate comments towards other residents. It’s being alleged a resident is constantly disturbing other residents and making inappropriate remarks. LPA interviewed 5 out of 59 residents in total. 4 out of 5 residents confirmed the allegation to be true. One resident was unavailable for an interview. R1 states, “the staff never say anything. They just sit there. They hear it and see it but don’t say anything. I don’t know if it’s their job or not. They don’t do anything.” R2 states, “I don’t think the staff are doing anything. I don’t think they can do much.” R3 states, “the staff don’t intervene when there is conflict.” R4 states, “that was one of the problems, you think the staff would pull a resident aside to figure out what’s going on. That never happened.”

During interviews with staff and witnesses, LPA Agard interviewed 2 out of 20 staff and 2 witnesses. 4 out of 4 confirmed the allegation to be true. S1 states, “there are 2 residents that are challenging each other verbally. It has escalated to the point that our legal team is involved. We are waiting for guidance from legal on how to handle this situation because both residents are doing it to each other.” S2 states, “things happen in the common areas or parking lot and staff aren’t monitoring the parking lot. As far as during dining time, staff have failed to report R3. W1 states, “I have tried to intervene, but you really can’t because you will get verbally attacked by either resident.” W2 states, “the staff can’t really get involved.”

LPA reviewed several code of conduct reports given to R3 and R4. Dates ranging from February 2021 to September 2022 and July 2021 to September 2022, respectively. Reports speak to residents violating the code of conduct in various capacities and causing disturbances to other residents. LPA Agard also reviewed several incident reports involving R3 and R4 over the past year and a half.

Regarding the allegation: Staff did not prevent a resident from making inappropriate comments towards other residents. Based on the interviews and record reviews conducted the “preponderance of the evidence” standard has been met; therefore, this allegation is substantiated. Title 22 Division 6 Chapter 8 Article 8 is being cited (please see LIC9099D.)

An exit interview was conducted and a copy of this report and appeal rights were given.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20221019121217
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2022
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities. To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidence by:
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Administrator will develop a conflict resolution plan to mitigate the disturbances being caused to other residents by R3 and R4. Administrator will share this plan with staff and train them on how to deescalate conflict between residents. Completion of plan and training is due to LPA via email or fax by POC due date.
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Based on interviews and record review, R3 and R4 have continued to caused disturbances within the facility. It is unclear what immediate actions are being implemented went these occurrences occur. It is also unclear what the facility is doing in the moment to deescalate the disturbance and inappropriate remarks. This poses a potential health and safety risk to residents in care.
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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 CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3