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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608840
Report Date: 09/21/2023
Date Signed: 09/21/2023 04:25:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/02/2021 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211202152342
FACILITY NAME:BEVERLY HILLS SENIOR CAREFACILITY NUMBER:
197608840
ADMINISTRATOR:ANNIE JIANGFACILITY TYPE:
740
ADDRESS:1015 S. ORANGE GROVE AVENUETELEPHONE:
(323) 933-8271
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:0CENSUS: 0DATE:
09/21/2023
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Dana OrdonezTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident had a fall resulting in a fractured hip
Resident is over medicated
Resident was not changed timely
Staff did not follow physicians orders for administering medication
Staff did not call residents physician due to the resident not eating or drinking
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced subsequent complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Dana Ordonez and explained the reason for the visit.

The facility is under a new change of ownership, effective 12/08/22; therefore, LPA Gonzalez will mail findings to (former) Licensee.

The investigation consisted of: During the initial visit conducted on 12/06/21, LPA Gonzalez requested a copy of Staff and Resident rosters. LPA also conducted a tour of entire facility inside and out with Administrator Patria Dufrenne. LPA did not observe any immediate Health & Safety concerns during the visit. On 03/15/23, LPA served Investigative Subpoena Duces Tecum to CT Corporation System requesting copies of hospital


(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
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 5
Control Number 28-AS-20211202152342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS SENIOR CARE
FACILITY NUMBER: 197608840
VISIT DATE: 09/21/2023
NARRATIVE
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records for R1. On 04/21/23, LPA received Cedar Sinai Medical Center copies of hospital records. On 09/21/23, LPA collected copies of Staff and Resident rosters. LPA interviewed Administrator Dana Ordonez, Staff 1-3 (S1-3), Residents 1-5 (R1-5), reviewed R1's facility file and collected copies of documents pertinent to investigation. LPA additionally conducted a tour of the facility which consisted of inspection of facility lobby, kitchen, dining room, medication room, a random selection of resident rooms which included resident private bathrooms. LPA additionally reviewed R1-5's medications and Medication Administration Records (MARs).

Investigation revealed the following: Regarding allegation, Resident had a fall resulting in a fractured hip, it is alleged that a facility resident fell on or about 11/12/21 resulting in a fractured hip. A staff at the facility allegedly stated that the resident slipped on a rug that was by the resident's bed. This same staff allegedly just kicked the rug into a corner and then threw the rug away. Interviews conducted with Administrator Patria Dufrenne, Administrator Dana Ordonez and S1-3 revealed that there was not an incident on or about 11/12/21 in which a resident fell and it resulted in a fractured hip. Staff denied that any resident slipped due to a rug. Staff deny kicking any rugs to the corner and then throwing it out. Staff stated that if any resident falls for any reason they are immediately assisted and proper assessment is conducted of the resident as well as any appropriate follow up medical attention is given if it is needed. S3 denied ever saying that any resident slipped on a rug by their bed and denied ever just kicking a rug into a corner and then throwing it away. Staff stated that if any furniture or items such as rugs are in a state of disrepair or are a danger to facility residents they are immediately removed and thrown outside in the trash and they are replaced. 5 out of 5 residents stated they have not fallen due to any broken furniture or rugs being a hazard. They stated that furniture throughout the facility is not in disrepair. They stated that if something breaks or does not work they let staff know and they immediately remove any broken furniture. R1 is no longer a resident of the facility. LPA did not observe any furniture in disrepair or any loose rugs in resident rooms during the tours conducted on 12/06/21 and 09/21/23. LPA observed facility furniture and rugs to be in good repair. LPA reviewed R1's medical records which revealed that R1 was seen at Cedars Sinai Medical Center on 11/13/21 for other medical reasons and did not observe on the medical records that R1 was seen due to a fall that resulted in a fractured hip. LPA did observe on the history section of R1's medical records that R1 had sustained a hip fracture in the past. Based on interviews conducted with facility staff, facility residents, and LPA observations and record review, there was not enough supportive evidence to concur with the reported allegation.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20211202152342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS SENIOR CARE
FACILITY NUMBER: 197608840
VISIT DATE: 09/21/2023
NARRATIVE
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For allegation, Resident is over medicated, it is alleged that the facility was over medicating R1due to R1 not being themselves and being out of it. It is also alleged that R1 appeared to be in pain and was seen to be in a fetal position. It is also alleged that Kaiser Hospital prescribed medications such as Seroquil, Morphine and Oxycodone. A facility staff allegedly stated that the R1 should not be taking that medication and stated to "throw it away". Facility staff was allegedly seen throwing all the medication away in a red container. Interviews conducted with Administrator Dufrenne, and facility staff revealed that facility residents receive their medications at the proper dosage times on a daily basis as prescribed by their doctor. Facility staff stated that when medication is given to residents staff will initial appropriate resident MAR each time medication is given. Staff stated that only prescribed medication is given to residents. Administrator Dufrenne denies ever just telling one of her staff to throw away any medication just based on a conversation with a resident's family member and she stated that medications are only discarded if a resident's doctor has discontinued a certain medication. She stated that the discontinued medications will be properly discarded by staff. She stated that no resident is being over medicated, and stated that R1 did appear to be in pain on 11/13/21 and did not seem themselves which is why it was decided to call 911. She stated that this was reported to R1's family. S3 denied being told by Administrator Dufrenne to throw any resident's medication out. Interviews conducted 5 out of 5 facility residents revealed that they do not have any concerns regarding medication management and indicated that they receive their medications at the appropriate times that they have to take them. 5 out of 5 residents stated that they are only given medications that are prescribed to them by their doctors. LPA reviewed R1-5 MARs records and observed that medication is given to residents at correct times and then properly initialed by staff. On 09/21/23, LPA observed as staff was administering medications to facility residents and did not observe anything of concern. LPA observed some residents request their medications and also observed staff call residents to come to medication room to get their medications. LPA review of R1's records revealed that R1 was being given only the medication that was prescribed to them. Based on interviews conducted with facility staff, facility residents, LPA review of records and observations, there was not enough supportive evidence to concur with the reported allegation.

For allegation, Resident was not changed timely, it is alleged that on 11/13/21 a facility resident's diaper was observed to be "soaked" and it appeared as if the resident's diaper had not been changed for a while.
Interview with Administrator Dufrenne revealed that at no time has a resident been left in a soiled diaper for a long period of time. She stated that there are some residents that require assistance with Activities of Daily Living (ADLs) and that staff tend to them immediately when there has been an accident. She stated that every resident has a call button and staff respond to an alert immediately to check on residents and tend to their needs. S1-3 stated that that staff immediately respond when a resident pushes their call button and
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20211202152342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS SENIOR CARE
FACILITY NUMBER: 197608840
VISIT DATE: 09/21/2023
NARRATIVE
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stated that residents are not made to wait for long periods of time. S1-3 denied that any resident has ever been left in a soiled diaper for an extended period of time. They stated that if a resident has had an accident the longest a resident will wait is from the time a resident pushes the call button to when the staff reaches the resident in their room. They stated that it will only be about 2-5 minutes and not longer than that. Staff stated that if a resident happens to not use a call button they are constantly conducting rounds and checking in on residents to see if they need any assistance or help with anything. Interviews conducted with 5 out of 5 residents revealed that they are satisfied with all the services they get at the facility and stated that they do not have any concerns, and staff are very helpful. 4 residents stated that they are independent and do not any assistance with their ADLs. 1 resident stated that they require assistance with their ADLs and that they have never had to wait long for staff to assist them and stated that they have never been left in soiled diapers for a long period of time. Resident stated that staff constantly check in on them and stated that they are happy with the care that they receive on a daily basis. LPA observed staff assisting residents and did not observe anything of concern. R1 is no longer a resident of the facility. LPA also observed the residents to be dressed appropriately with clean clothes an no bad odors. Residents were observed to have good hygiene. Based on interviews conducted with facility staff, and facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

For allegation, Staff did not follow physicians orders for administering medication, it is alleged that the facility staff gave a resident medication even when the resident was not eating or drinking and that staff stated that they would give spoonfuls of water to the resident for the medication. Interviews conducted with Administrator Dufrenne, and facility staff revealed that facility residents receive their medications at the proper dosage times on a daily basis as prescribed by their doctor. Facility staff stated that when medication is given to residents staff will initial appropriate resident MAR each time medication is given. Staff stated that the medications are given to residents as prescribed by the doctor. They stated that if a medication has to be taken with food they ensure that the medications are given to them with their meals. They stated that they do give residents water when they are given their medications but that they give the residents water in a cup and not by spoon. Interviews conducted 5 out of 5 facility residents revealed that they do not have any concerns regarding medication management and indicated that they receive their medications at the appropriate times that they have to take them as prescribed by their doctor. 5 out of 5 residents stated that if they have to take any of their medications with food, the staff give them their medications with a meal. LPA reviewed R1-5 MARs records and observed that medication is given to residents at correct times and then properly initialed
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20211202152342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS SENIOR CARE
FACILITY NUMBER: 197608840
VISIT DATE: 09/21/2023
NARRATIVE
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by staff. On 09/21/23, LPA observed as staff was administering medications to facility residents and did not observe anything of concern. LPA observed some residents request their medications. LPA observed staff call residents to come to medication room to get their medications and also observe staff give residents their medications when they were having their lunch. Based on interviews conducted with facility staff, facility residents, LPA review of records and observations, there was not enough supportive evidence to concur with the reported allegation.

For allegation, Staff did not call residents physician due to the resident not eating or drinking, it is alleged that a facility staff stated that a resident had not been eating or drinking for a few days and that the resident's physician was not notified that the resident had not been eating or drinking. Interviews conducted with Administrator Dufrenne, and facility staff revealed that when staff observe that a resident is not eating or drinking they will notify the resident's doctor and the resident's responsible party, if they have one. They stated that if a resident is observed to be weak they will arrange transportation to the hospital so that the resident can be properly evaluated and treated. They stated that when this happens they make the proper reports to all applicable agencies such as Community Care Licensing Division (CCLD), and Long Term Care Ombudsman (LTCO). Administrator stated that R1 did appear to be in pain on 11/13/21 and did not seem themselves which is why it was decided to call 911. She stated that this was reported to R1's family. Interviews conducted with 5 out of 5 residents stated that they are only given medications that are prescribed to them by their doctors and as prescribed by their doctor. They also stated that staff are in communication with their doctors. R1 is no longer a resident of the facility. On 09/21/23, LPA observed as staff was tending to facility residents needs and did not observe anything of concern. LPA observed staff assisting residents with their medications, and also ensuring that residents were eating their meals. Based on interviews conducted with facility staff, facility residents, LPA review of records and observations, there was not enough supportive evidence to concur with the reported allegation.

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.

Facility has been closed as of 12/07/22. Reason for closure was change of ownership.

Exit interview was not conducted, a hard copy of the Complaint Report, and Appeal Rights will be mailed to Licensee New Home for Me, Inc.'s (#197608840) last known mailing address.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5