197608840-2-10-2021-28-AS-MVAO-BZMMPB-20210331094650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608840
Report Date: 02/08/2021
Date Signed: 02/10/2021 03:05:38 PM

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
01/23/2020 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200123075846

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: 37	DATE:	02/08/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator Pat Dufrenee		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Lack of supervision resulting in multiple falls
Facility staff failed to assist residents in a timely manner
Facility staff failed to provide adequate food service

INVESTIGATION FINDINGS:

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The purpose of this report is to deliver findings from the original complaint dated 1/23/2020.
On initial visit 1/27/2020 the following occurred:
LPA toured the facility today 1/27/2020 at 11:45 AM along with Administrator Jennifer Rivas in which there are 45 Resident Rooms.
LPA toured Rooms 101, 103, 105, 106,201,203,205 and 207 and there were no health and safety concerns observed. LPA toured the kitchen and observed a sufficient food supply and lunch being served that was well balanced.
Administrator Jennifer Rivas was interviewed at 11:30 AM.
Interviews were conducted with Resident 1-4 at 11:50 AM to 12:30 PM.
Administrator to submit Special Incident Reports (SIR's) to Licensing.
In regards to the allegation Lack of supervision resulting in multiple falls, based on interviews conducted and

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

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 28-AS-20200123075846

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: 02/08/2021

NARRATIVE

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information gathered when there have been falls staff have been quick to respond and will be there quickly to provide timely medical attention.
There has not been negligence observed by staff regarding to any falls and that staff have been efficient and professional.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
In regards to the allegation Facility staff failed to assist residents in a timely manner, based on interviews with residents on 1/27/2020 the staff are very professional and have always given timely medical attention and have responded quickly with any falls.
They have even had caregivers on 2nd floor assist with a fall on the first floor when they have heard it.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
In regards to the allegation Facility staff failed to provide adequate food service, based on interviews conducted, and tour of the facility conducted on 1/27/20 there is a sufficient supply of food in the kitchen and the lunch meal was well balanced. Resident's stated that there was a variety of food and enough supply to get 2nds
.Although the allegations may have happened or are 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: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
01/23/2020 and conducted by Evaluator Glenn Trueman

COMPLAINT CONTROL NUMBER: 28-AS-20200123075846

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: 37	DATE:	02/08/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Pat Dufrenee		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff failed to provide a safe/clean environment for residents in care

INVESTIGATION FINDINGS:

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In regards to the allegation Facility staff failed to provide a safe/clean environment for residents in care, based on interviews conducted with residents the housekeeping staff has not always cleaned up resident rooms. One client stated that excrement is left in the garbage after removing the plastic bad and bedware at times is not changed for weeks.
Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20200123075846

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/08/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensing to review Regulation 87303 and self certify facility to be clean, safe, sanitary and in good repair at all times.
	8 9 10 11 12 13 14	Based on interviews conducted licensee failed to have facility clean, sanitary and in good repair with housekeeping staff has not always cleaned up resident rooms with excrement left in the garbage after removing the plastic and bedware at times is not changed for weeks which caused an Immediate, health and Safety concern for residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

LIC9099 (FAS) - (06/04)

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