197608787-9-12-2023-11-AS-JHAD-CW8SCF-20231002134528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608787
Report Date: 09/12/2023
Date Signed: 09/12/2023 09:43:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
01/27/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230127161652

FACILITY NAME:	MERIDIAN AT OCEAN VILLA		FACILITY NUMBER:	197608787
ADMINISTRATOR:	SHAWN C MOONEY		FACILITY TYPE:	740
ADDRESS:	413 OCEAN AVE		TELEPHONE:	(310) 393-0242
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90402
CAPACITY:	0	CENSUS: 0	DATE:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:			TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff caused a fracture to a resident while in care.
Staff mishandled a resident during a transfer.
Staff did not manage a resident's incontinence needs which resulted in infection.

INVESTIGATION FINDINGS:

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On 09/12/23, Licensing Program Analyst (LPA) Ernand Dabuet rendered the investigation findings via USPS certified mail due to the Licensee surrendering the License on 3/3/23. The licensee 413 SM Meridian Holdings; Meridian SR. LVG. LLC is served with this complaint investigation report through USPS Certified Mail.

The investigation consisted of the following: LPA Dabuet conducted the 10-day visit on 01/30/23 with former executive director Anita Csukardi. LPA toured the facility Csukardi and requested copies of the following documents: Facility staff and Resident rosters; Admission Agreement, Appraisal/Needs and Services Plan, Physician’s Report, medical records (to include hospital records), Medication Administration Records and Unusual Incident/Injury Report for Resident #1 (R1). A plant inspection of the facility.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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 7

Control Number 11-AS-20230127161652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MERIDIAN AT OCEAN VILLA	FACILITY NUMBER: 197608787
	VISIT DATE: 09/12/2023

NARRATIVE

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A separate investigation was conducted by the Department of Social Services, Investigator Juan Lozano that included a review of hospital medical records, interview with witness, facility staff, and facility residents.

INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff caused a fracture to a resident while in care.
Allegation #2: Staff mishandled a resident during a transfer.

The investigation revealed that on 01/24/23 Resident #1 (R1) was treated at Providence Saint John’s Health Center after being examined by (R1’s) primary physician witness #2 (W2) that same day. Medical records revealed (R1) left tibia and fibula was fractured and diagnosed with severe sepsis with acute organ dysfunction. (W2) assessed (R1’s) left leg and noted that (R1) left leg had bruising and was very tender to touch. (W2) assessment noted that (R1’s) sepsis was probably catheter associated with cystitis. (R1) was then transferred to Kaiser Permanente Hospital on 01/25/23 through 02/03/23 due to sepsis.

Details of the complaint indicated on 1/22/23, two staff people were trying to move (R1) from the bed to the wheelchair and dropped (R1). (R1) complained of leg pain with a hematoma on the knees, swelling and dried blood, and bruising. Evidence and statements made by staff #1 - #4 (S1-S4) there is no reason to believe that (R1’s) left leg was fractured on 01/22/23 while being transferred from a wheelchair to (R1’s) bed was due to neglect/lack of supervision. Investigation revealed (S3) held (R1) wheelchair as (S1-S2) transferred (R1) from the bed to the wheelchair. In transferring (R1) unforeseen accident occurred that resulted in (R1) sliding to the ground that caused (R1) to end up in an upright position on both knees. (S2) stated in the process of (R1) being transferred from bed to wheelchair (R1) lost the strength in the legs and had no support to uphold the (R1's) body weight. Interviews with (S1-S4) revealed consistent with what had happened on 01/22/23 and (S1-S4) were all present during the incident and attempted to transfer (R1) from the bed to the wheelchair. As a result of an interview with (R1), (R1) recalls a fall, however (R1) is unable to recall the details regarding the means by which (R1) had fallen. (S1-S2) denied ever dropping residents in the past. Interviews with two independent residents #2 -#3 (R2-R3) that received care from (S1-S2) were complimentary of both staff.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 11-AS-20230127161652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MERIDIAN AT OCEAN VILLA	FACILITY NUMBER: 197608787
	VISIT DATE: 09/12/2023

NARRATIVE

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Based on interviews, observations, and supporting medical records the preponderance of evidence standard has not been met; therefore, the allegations mentioned above of NEGLECT/LACK OF CARE AND SUPERVISION are substantiated.

Allegation #4: Staff did not manage a resident's incontinence needs which resulted in infection.

The details of the complaint reported resident #1 (R1’s) catheter bag was cloudy on 01/23/23 a sign incontinence needs are not being met which resulted in an infection.

The investigation conducted by investigator Lozano, revealed while resident #1 (R1) was in care at this facility, (R1) had a Foley catheter due to a medical history condition of urinary retention. (R1’s) primary physician witness #2 (W2) indicated it is common for an individual with chronic Foley catheters to get urinary tract infections (UTI) from bacteria due to the Foley catheter. (W2) assessed (R1) on two separate occasions, on one occasion in October 2022, (W2) observed that (R1) had feces in diaper. (W2) immediately informed the facility staff the soiled diaper was subsequently changed. According to (W2) the stool was approximately one to two hours old. (W2) completed an assessment of (R1) and had not noted any indicated damage to (R1’s) skin that would have been caused by fecal matter. As a result of interviews with (S1-S2), residents changed diapers and rotating residents with bed sores every two hours or as needed. Interviews with residents #2-#3 had no issues with incontinence or concerns about how they were cared for by staff at this facility.

Based on interviews, observations, and supporting medical records the preponderance of evidence standard has not been met; therefore, the allegation mentioned above of NEGLECT/LACK OF CARE AND SUPERVISION is unsubstantiated.

Based on the information collected, an inspection of the facility, observation, record reviews, and interviews conducted, the Department found no evidence to support the allegations in this complaint.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
01/27/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230127161652

FACILITY NAME:	MERIDIAN AT OCEAN VILLA		FACILITY NUMBER:	197608787
ADMINISTRATOR:	SHAWN C MOONEY		FACILITY TYPE:	740
ADDRESS:	413 OCEAN AVE		TELEPHONE:	(310) 393-0242
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90402
CAPACITY:	0	CENSUS: 0	DATE:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:			TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff did not ensure a resident consumed an appropriate amount of fluids while in care.
Staff did not properly report an incident involving a resident .

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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 7

Control Number 11-AS-20230127161652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MERIDIAN AT OCEAN VILLA	FACILITY NUMBER: 197608787
	VISIT DATE: 09/12/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #3: Staff did not ensure a resident consumed an appropriate amount of fluids while in care.

The details of the complaint alleged resident #1 (R1) required assistance with hydration was not provided the amount of water and was dehydrated. The complainant reported that (R1) needed assistance unscrewing a water bottle, as (R1's) hands do not work well. This is neglectful of the staff, according to the complainant (R1).

Physician's Medical Orders prescribed nine (9) medications for (R1). (5) out of (9) daily medications caused side effects of dehydration or dry mouth per the Mayo Clinic. (R1's) Physician's Report dated 02/19/21 indicated (R1's) mental condition did not suffer from memory loss. (R1) can follow instructions, able to communicate needs, and able to feed self. Resident Assessment for (R1) dated 02/16/21 revealed no assistance required with eating, no assistance needed in opening food containers, cutting food, and staff encouragement. (R1's) Resident Notes indicated fluids were given with meals and medications.

On 02/07/23 between 9:30 am and 10:45 am, the Department interviewed by telephone staff (3) out (3) staff (S1-S3) reported that they had never observed (R1) in a dehydrated state. (S1-S2) reported that based on (R1's) medical assessment, (R1) required status checks each shift due to recent hospitalization, illness, or medication changes. (S1-S3) confirmed that liquids are offered with meals along with daily snacks. (R1) also consumes liquids with daily medications. (S3) reported that residents are able to request for additional beverages from staff aside from the regular schedule.

On 03/23/23 at 10:30 am the Department interviewed (R1) by telephone who confirmed being a former resident at this facility. (R1) reported that being able to feed and consume liquids by self. According to (R1) did not need assistance with opening a water bottle nor ever felt the need for more liquids. (R1) claimed to never have felt dehydrated as liquids were available with medications, meals, and snacks. (R1) claimed there was no shortage of fluids and that staff were attentive to respond to (R1's) needs.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 11-AS-20230127161652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MERIDIAN AT OCEAN VILLA	FACILITY NUMBER: 197608787
	VISIT DATE: 09/12/2023

NARRATIVE

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On 03/23/23 between 12 pm - 1 pm, the Department interviewed family representatives of former residents by telephone. (4) out of (4) witnesses (W1-W4) reported residents are provided water with medications. A wide variety of juices, milk, coffee, and tea are available with meals. There were liquid refreshments available daily upon request. (W1-W4) were complimentary of the staff and expressed the staff was attentive and responsive to the care and supervision of residents.

Based on interviews, observations, and supporting records the preponderance of evidence standard has not been met; therefore, the allegation mentioned above of NEGLECT/LACK OF CARE AND SUPERVISION is unsubstantiated.

Allegation #5: Staff did not properly report an incident involving a resident.

It is alleged that staff did not properly report an incident involving resident #1 (R1). The complainant reported that the facility staff failed to report an incident that happened on 10/24/222 when (R1) was mishandled while being transferred from bed to a wheelchair.

The Department reviewed (R1's) service records including incident reports for 10/24/22 and 01/24/23 which involved (R1). It revealed (R1's) medical physicians, Community Care Licensing, and family representatives were notified by the facility regional nurse. Resident Notes for (R1) included notification of responsible parties.

On 02/07/23 between 9:30 am - 10:45 am the Department interviewed by telephone staff (2) out (3) staff (S1-S2) incidents for (R1) on 10/24/22 and 01/24/23. (S1-S2) confirmed incidents are documented in the Resident Notes and responsible parties are notified.

On 03/23/23 at 10:30 am the Department interviewed (R1) was uncertain if incidents were reported. However, (R1) stated the staff are accountable and would have done the proper thing.

On 03/23/23 between 12 pm - 1 pm, the Department interviewed family representatives for residents by telephone. (4) out of (4) witnesses (W1-W4) reported the facility is very much involved in the care and supervision of residents. (W1-W4) claimed the facility staff was proactive in notifying the responsible parties.
(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 11-AS-20230127161652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MERIDIAN AT OCEAN VILLA	FACILITY NUMBER: 197608787
	VISIT DATE: 09/12/2023

NARRATIVE

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Based on interviews, observations, and supporting records the preponderance of evidence standard has not been met; therefore, the allegation mentioned above of NEGLECT/LACK OF CARE AND SUPERVISION is unsubstantiated.

Based on the information collected, an inspection of the facility, observation, record reviews, and interviews conducted, the Department found no evidence to support the allegations in this complaint.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

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