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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608410
Report Date: 07/27/2022
Date Signed: 07/28/2022 12:15:53 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20220420140039
FACILITY NAME:LAURELGROVE MANORFACILITY NUMBER:
197608410
ADMINISTRATOR:SELVA W BANOSFACILITY TYPE:
735
ADDRESS:7841 LAURELGROVE AVENUETELEPHONE:
(818) 255-4733
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:4CENSUS: 3DATE:
07/27/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Selva BanosTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff speaks to resident in an inappropriate manner.
INVESTIGATION FINDINGS:
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On 07/27/2022, Licensing program Analyst Sandra Urena conducted a subsequent unannounced visit to deliver the findings for the allegations named above. LPA Urena arrived at the facility at 11:00 a.m., and met with facility staff. LPA Urena spoke with the Administrator at 12:15 p.m., over the phone and explained the reason for the visit.
On 4/27/2022, the LPA conducted an unannounced visit, interviewed resident, staff, administrator and collateral agency representatives from 1:45 p.m. to 3:30 p.m

Staff speaks to resident in an inappropriate manner.
It is alleged that ‘Staff speaks to resident in an inappropriate manner’. The concern of the Reporting Party (RP) is that the S1 spoke to the R1 in a loud voice during a verbal exchange between S1 and R1. To investigate this complaint the LPA conducted interviews with residents, facility staff, and representatives from collateral agencies. Continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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 6
Control Number 29-AS-20220420140039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE MANOR
FACILITY NUMBER: 197608410
VISIT DATE: 07/27/2022
NARRATIVE
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The LPA interviewed staff at 1:45 p.m. about speaking in an inappropriate manner to residents, and staff stated that they are always patient, ‘I tell them that it’s not OK to use that language(bad)and when they yell’. At 2:15 p.m., the LPA interviewed residents about staff’s communication style with residents, and residents stated that staff are respectful when they speak with residents. The LPA interviewed the administrator, and the administrator stated that staff are courteous, and speak in a respectful manner to residents. At 3:00 p.m. the LPA interviewed representatives from collateral agencies, and it revealed that on 04/06/2022, S1 and R1 engaged in a verbal exchange. According to a credible witness, the verbal exchange was initiated by the R1, because R1 felt they were being accused by S1 of stealing the house mail. During the verbal exchange, R1 started to ‘yell’ at S1, then S1 started to ‘yell’ back at R1 in an inappropriate manner, while speaking with R1. According to the witness, the verbal exchange lasted approximately two (2) minutes, and at the end of the verbal exchange, R1 sat next to the witness, and S1 walked away.

Based on the interviews, there is sufficient evidence to support the claim that ‘staff speaks to resident in an inappropriate manner. Therefore, this allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).

Exit interview was conducted with the facility representative via phone call. The representative agreed to sign the report and return to the office. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220420140039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAURELGROVE MANOR
FACILITY NUMBER: 197608410
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited
CCR
87468.1(a)
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87468.1(a) Personal Rights -Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidence by:

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Administrator agrees to review personal rights with staff and send a copy of the signing sheet and documents reviewed by 7/29/2022.

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Based on interviews with cerdible witness, staff spoke inappropriately to resident in care which poses a potential health and safety, personal risk to persons 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20220420140039

FACILITY NAME:LAURELGROVE MANORFACILITY NUMBER:
197608410
ADMINISTRATOR:SELVA W BANOSFACILITY TYPE:
735
ADDRESS:7841 LAURELGROVE AVENUETELEPHONE:
(818) 255-4733
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:4CENSUS: DATE:
07/27/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident is not provided adequate food service.
Resident is not treated with dignity and respect.
INVESTIGATION FINDINGS:
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On 07/27/2022, Licensing program Analyst Sandra Urena conducted a subsequent unannounced visit to deliver the findings for the allegations named above. LPA Urena arrived at the facility at 11:00 a.m. and met with facility representative, Selva Banos, and explained the reason for the visit.

On 04/27/2022, LPA Urena conducted an unannounced visit. LPA Urena and the administrator conducted a brief tour of the facility. The LPA conducted resident and staff interviews from 1:45 p.m. to 3:30 p.m.

Resident is not provided adequate food service.
It is alleged that the ‘Resident is not provided adequate food service’. The concern of the RP is that R1 is not provided with meals, and R1 is prohibited from taking food from the facility refrigerator's when R1 is hungry. LPA Urena interviewed resident, staff, and administrator, and conducted a tour of the kitchen. Continues on LIC 9099 C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20220420140039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE MANOR
FACILITY NUMBER: 197608410
VISIT DATE: 07/27/2022
NARRATIVE
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 Interview with residents revealed that residents can get snacks as they choose. Sometimes residents prepare their own meals under supervision; if residents don’t like what was prepared for them, or may order take out from a fast food place. Residents stated that they receive three meals a day, and snacks to eat as they choose throughout the day. Interview with facility staff revealed that residents can eat snacks as they choose to do so. Furthermore, staff stated that they prepare daily meals for the residents. Staff request that all residents keep out of the kitchen after 8:00 p.m. Interview with the administrator revealed that residents are provided with three meals a day, and snacks are available for the residents. The administrator stated that R1 is allowed to cook meals during the day. However, when R1 cooks, R1 refuses to allow other residents in the kitchen while R1 is cooking (sometimes up to three hours at a time). Administrator added that residents have full access to the kitchen. During the tour of the kitchen, the LPA observed snacks, and fresh fruit readily available on the kitchen counter. Refrigerator was stocked with vegetables, milk, juice and other foods. Freezer was stocked with frozen meats, and other frozen foods.

Based on the information gathered through the interviews, and observations there is insufficient evidence to support the claim that residents are not provided with adequate food service. Therefore, although the allegation may have happened, or may be valid, this allegation is deemed Unsubstantiated at this time.

Resident is not treated with dignity and respect.



It is alleged that the ‘Resident is not treated with dignity and respect’. The concern of the RP is that R1 is not allowed to eat the food bought, and or prepared for all residents; consequently making R1 feel that they are not treated with respect, and dignity. The LPA interviewed residents, staff, and administrator. Interview with residents revealed that they are allowed to eat meals, and food that is bought for them. Food has not been denied to them. They have not experienced staff refusing food to them or to other residents.

Continues on LIC 9099-A...
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220420140039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE MANOR
FACILITY NUMBER: 197608410
VISIT DATE: 07/27/2022
NARRATIVE
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Dinner is served at 5:00 p.m, but if residents are still hungry after dinner they get snacks and or more food. Residents stated that the staff treat residents with respect. The staff interview revealed that the kitchen is open to all residents during the day, however residents are limited from accessing the kitchen during the evening hours. Staff stated that the kitchen is closed after 8:00 p.m. for cooking purposes, but residents are allowed to take anything they want from the refrigerator as needed. Interview with administrator revealed that residents are restricted from cooking in the kitchen after 8:00 p.m.

Based on the information gathered through the interviews, there is insufficient evidence to support the claim that the staff are not treated with dignity or respect. Therefore, although the allegation may have happened, or may be valid, this allegation is deemed Unsubstantiated at this time.

Exit interview was conducted with the facility representative via phone call. The representative agreed to sign the report and return to the office. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6