197608840-10-26-2022-28-AS-LHIS-CS4JBR-20230523065443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608840
Report Date: 10/26/2022
Date Signed: 10/26/2022 12:55:32 PM

Unsubstantiated

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
09/30/2021 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210930132006

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: 43	DATE:	10/26/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Staff #1 Jennifer Rivas, Office Manager		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility is mismanaging client's finances.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 Jennifer Rivas, Office Manager. LPA/RA spoke to S1 prior to entering the facility to conduct a risk assessment. S1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation(s). An initial 10-Day visit was conducted by LPA Nicol Wesley on 10/07/21 with Staff #1 (S1: Jennifer Rivas); as Administrator (A1: Patria Dufrenne) was unavailable during the time of this visit.

LPA/RA re-interviewed (between 11:00 am - 11:45 am) two (2) staff members (A1 & S1) and interviewed three (3) residents in care (R2-R4). Administrator Dufrenne was interviewed (via telephone). Resident #1 was not interviewed as the resident moved on 04/12/22. LPA/RA reviewed (between 11:45 am – 12:30 pm) requested documents: Admissions Agreement (dated 01/25/21), Physician’s Report (dated 01/06/21), Emergency I.D. & Information (dated 02/04/21), Text Messages (between R1's Payee and Administrator from 06/08/21

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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-20210930132006

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: 10/26/2022

NARRATIVE

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thru 01/18/22), SSI Letter (dated 04/30/21), R2 - R4 P & I Ledgers, Facility Staff & Residents rosters, and Unusual Incident/Injury Report (dated 04/12/22).

Regarding Allegation #1: this investigation revealed based on interviews conducted corroborated that the facility manages three (3) residents' P & I funds. Residents corroborated that they do receive their monthly SSI allowances and their funds have not been mismanaged by facility staff in all the years residing at the facility. (LPA/RA Ceniceros reviewed Residents #2 - #4 P & I funds for the fiscal year of 2021/2022.) LPA/RA reviewed (former) Resident #1's (R1) facility records and observed the Physician's Report capacity for self care documented that R1 was not able to manage own cash resources; therefore, R1's Payee was a family member (Daughter). A review of Resident #1's Identification and Emergency Information did not document R1's family member (Daughter) as other persons to be notified in emergency and R1 was own responsible person. Text messages revealed that R1's family member (SSI Payee) had not been paying R1's rent with an outstanding balance of Eight-thousand Eight-hundred Forty Dollars ($8,840). Facility then submitted an application to SSI to become R1's payee; however, Resident #1 would later be hospitalized and then transferred to a skilled-nursing facility and did not return to the facility. (LPA/RA reviewed the Unusual Incident/Injury Report, dated 04/12/22).

Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Facility is mismanaging client's finances is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Staff #1 Jennifer Rivas, Office Manager.

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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