197608491-6-5-2021-31-AS-MVAO-C54LTD-20210720090206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608491
Report Date: 06/05/2021
Date Signed: 06/05/2021 10:11:55 PM

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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/19/2021 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210219155219

FACILITY NAME:	ACE SENIOR CARE		FACILITY NUMBER:	197608491
ADMINISTRATOR:	ELAINE BOTE		FACILITY TYPE:	740
ADDRESS:	22910 SHERMAN WAY		TELEPHONE:	(818) 914-5002
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 1	DATE:	06/05/2021
		UNANNOUNCED	TIME BEGAN:	06:30 PM
MET WITH:	Rosanna Remorin		TIME COMPLETED:	07:05 PM

ALLEGATION(S):

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Facility provided untimely medical attention
Facility staff are not wearing masks

INVESTIGATION FINDINGS:

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An unannounced susbequent complaint visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon arrival LPM met with staff Rosanna Remorin. LPA contacted the administrator via telephone, administrator designated staff to sign for the report.

Regarding the allegation: Facilit provided untimely medical attention, it was reported that on 02/02/2021 facility staff were asked to call 911 due resident 1 (R1)'s condition, however staff failed to do so.

An initial 10 day complaint visit was conducted by LPA W. Smith on 2/23/2021 at whcih time interviews were held with the administrator telephonically/virtually. On 3/19/2021 LPA Avetisyan conducted additional interview with the administrator. Additionally on 3/19/2021 LPA requested Pre-Hospital Care Summary Report from Los Angeles Fire Department (LAFD). On 3/22/2021 LPA conducted interview with staff #2 (S2) and attempted to interview Staff #1 (S1). On 3/24/2021 LPA conducted interview with R1's responsible party/family. On 6/2/2021 LPA conducted interview with staff 1 (S1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2021

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 31-AS-20210219155219

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ACE SENIOR CARE	FACILITY NUMBER: 197608491
	VISIT DATE: 06/05/2021

NARRATIVE

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Copy of the Pre Hospital Care Report Summary was received on 3/23/2021 and documented that R1 was found in bed with staff doing compressions on chest. Family stated that R1 "gradually became altered". According to S1 who was working on the date of the incident they were in constant communications with R1's family, and checking R1's vitals consistently. R1's family/responsible party arrived to the facility in about an hour or so later, at which time R1 was responsive. While S1 was making dinner for the other resident R1's family screamed for her to call 911. Per S1 while waiting for emergency personnel her and R1's son took turns performing CPR. According to S1 if at anytime R1's vitals were alarming she would call 911 immediately however they were not until later on in the day. Based on the information obtained allegation is Unsubstantiated at this time.

Regarding allegation: Facility staff are not wearing masks it was reported that on various occasion staff members were observed without masks while working at the facility. During the course of the investigation interviews were conducted with administrator and staff. When interviewed all staff stated that they always wear masks and gloves while working at the facility. According to S1 and S2 that they are live in staff that do not go out however to protect themselves and residents they always wear masks when working. During the initial 10 day complaint visit conducted on 2/23/2021 and other virtual visit conducted by the department staff were observed to be wearing masks. Based on the information obtained allegation is unsubstantiated at this time.

Exit interview conducted and copy of report emailed to the administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2021

LIC9099 (FAS) - (06/04)

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