197608840-8-26-2020-28-AS-MVAO-BXXMA6-20210205082546

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608840
Report Date: 08/25/2020
Date Signed: 08/26/2020 11:25:48 AM

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/16/2020 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200416113856

FACILITY NAME:	BEVERLY HILLS SENIOR CARE		FACILITY NUMBER:	197608840
ADMINISTRATOR:	ANNIE JIANG		FACILITY TYPE:	740
ADDRESS:	1015 S. ORANGE GROVE AVENUE		TELEPHONE:	(323) 933-8271
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY:	45	CENSUS: 38	DATE:	08/25/2020
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Annie Jiang, Licensee		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility staff refused to accept resident back from the hospital.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver the finding for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Annie Jiang, Licensee.

On 4/22/2020, LPA Rivas conducted the initial investigation telephonically and requested for the facility's personnel report and resident roster. LPA also requested copies of the following documents pertaining to Resident #1 (R1): Hospital discharge document, Admission Agreement, Physician's Report, and Appraisal needs and services plan.

Investigation revealed the following for allegation - facility staff refused to accept resident back from the hospital. Based on the information gathered, Resident #1 was hospitalized on 4/10/20 due to a fall and was ready to be discharged on 4/14/20. (Continue on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020

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 28-AS-20200416113856

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS SENIOR CARE	FACILITY NUMBER: 197608840
	VISIT DATE: 08/25/2020

NARRATIVE

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Per Licensee, she denied not wanting to accept the resident back from the hospital but rather, she wanted to ensure that resident's health condition can be retained at the facility according to regulation. On 4/14/20, Licensee was informed by Cedar Sinai that resident was diagnosed with MRSA and wanted to request more information before she can determine if resident is allowed return to facility. On the same day, she was denied request to assess resident at hospital due to Covid-19 pandemic. The next day, 4/15/20, the Social Worker agreed to allow Licensee to visit the resident. On 4/16/20, Cedar's Sinai agreed on allowing the Licensee to visit resident at the hospital and a Covid-19 test was requested by the Licensee. On 4/17/20, the Licensee visited resident at the hospital to reappraise resident's current condition. The Social Worker indicated that resident was safe to return to facility and had a negative Covid-19 test result. Therefore, on 4/18/20, the resident returned to the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted. A copy of this report and appeal rights were discussed and sent to the Licensee, Annie Jiang for a signature.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020

LIC9099 (FAS) - (06/04)

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