197608840-5-5-2021-28-AS-MVAO-C2YMM6-20210513094324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608840
Report Date: 05/04/2021
Date Signed: 05/05/2021 09:42:15 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
12/07/2020 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201207124838

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: 41	DATE:	05/04/2021
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Patria Dufrene		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident is defecating outside of facility while in care.
Resident is trowing trash outside of facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong initiated a subsequent complaint investigation to deliver findings on 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 administrator Patria Dufrene

The investigation consisted of the following: On 12/14/2020, LPA conducted the initial 10 days complaint and the administrator and Staff#1 (S1) were interviewed. On 4/29/21, LPA interviewed five (5) residents and additional four (4) staff.

The investigation revealed of the following: Regarding allegation#1 “Resident is defecating outside of facility while in care.” LPA interviewed five residents and four residents denied the allegation and stated they had never seen any resident was defecating outside of the facility.
(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

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-20201207124838

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: 05/04/2021

NARRATIVE

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They only saw someone on the street doing it but not the resident resides in the facility. LPA interviewed staff and they all denied the allegation and stated that they never saw any resident was defecating outside of the facility. Based on the information, the allegation is UNSUBSTANTIATED.

In regard to allegation#2 “Resident is throwing trash outside the facility.” LPA interviewed five residents and three of them denied the allegation and stated they never see any residents throw trash outside the facility. LPA interviewed staff and they all denied the allegation and stated that Resident#1 (R1) only like throwing things into actual trash bin or the dumpster in the facility but not outside the facility. Based on the information obtained, the allegation is UNSUBSTANTIATED.

Based on statements and interviews conducted with staff and residents and there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

A telephonic exit interview was conducted with facility administrator Patria Dufrene. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC9099 (FAS) - (06/04)

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