197608232-11-20-2024-11-AS-RORN-DBMVRY-20241204154042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608232
Report Date: 11/20/2024
Date Signed: 11/20/2024 04:50:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
11/14/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20241114103411

FACILITY NAME:	SUMMER HOUSE AT LADERA HEIGHTS		FACILITY NUMBER:	197608232
ADMINISTRATOR:	SHERRYL RAFOLS		FACILITY TYPE:	740
ADDRESS:	6108 DAMASK AVENUE		TELEPHONE:	(323) 792-4105
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90056
CAPACITY:	4	CENSUS: 4	DATE:	11/20/2024
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Marilyn Nerry		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not ensure that resident was able to return to the facility after hospitalization.

INVESTIGATION FINDINGS:

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On 11/20/24, the department conducted an unannounced complaint visit to the facility listed above. The department met with Caregiver, Marilyn Nery, and the purpose of today's visit was explained.

During today’s visit the department toured the facility, interviewed Staff S1-S3, interviewed Residents R1-R3, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report, Preplacement Appraisal Information, Identification and Emergency Information, and Los Angeles County Sheriff’s Report Information.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

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-20241114103411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS	FACILITY NUMBER: 197608232
	VISIT DATE: 11/20/2024

NARRATIVE

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Allegation: Staff did not ensure resident was able to return to the facility after hospitalization.
The complaint allegation alleges that after a resident was transferred to the Emergency Department, they attempted to contact the facility staff multiple times, and later that day had the resident transferred back to the facility and nobody answered the door resulting in the resident being transferred back to the hospital.

During the facility tour, the department observed resident bedrooms are in the back of the facility. While at the facility, the department called the facility landline telephone, which rang, and had staff not answer it so the answering voicemail would pick up. Upon entry to the facility the department observed there is a ring camera at the entrance of the facility.

During an interview with the Administrator (S1), was asked if on the day of the incident if there were any notifications that there was someone at the door, they stated they did not receive any notifications on the evening of 11/10/2024.
During record review, the department observed S2 was working the night shift on 11/10/24.
During an interview with Staff S2, was asked if they were at the facility at 8PM on 11/10/24, S2 stated they were at the facility on that night and that at 8PM they are usually assisting residents with getting ready for bed and helping them into bed. Additionally, S2 stated they did not hear any knocking, or the doorbell ringing, or the telephone ringing.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241114103411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS	FACILITY NUMBER: 197608232
	VISIT DATE: 11/20/2024

NARRATIVE

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During interviews with staff S1-S3, were asked if there was a time when a resident returned from the hospital and staff were not available to receive a resident back, three (3) out of three (3) stated there is always staff at the facility and residents are always able to return to the facility. Additionally, Staff S1-S3 were asked if they heard anything from the hospital on 11/10/24, three (3) out of three (3) stated they had not heard or got any updates from the hospital, and that usually the nurse calls and gives update. Additionally, during an interview with Staff S1, was asked how they found out R1 was ready to be transferred back to the facility, S1 stated they were informed when a Los Angeles Sherriff’s contacted the other Administrator and informed them of an Elder Abuse Report regarding R1.
During interview with residents R1-R3, were asked if there was a time they left the facility and were unable to return to the facility or staff did not open the door, three (3) out of three (3) stated no, they have not experienced that. Additionally, during interviews with Resident R2 and R3 were asked if on the night on 11/10/24 if they heard the telephone keep ringing or somebody knocking on the door, or ringing the door bell, two (2) out of two (2) stated they did not hear anything.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

A technical violation was issued, please see attached LIC9102.

An exit interview was conducted with Caregiver, Marilyn Nery, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

LIC9099 (FAS) - (06/04)

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