197608840-5-7-2021-28-AS-MVAO-C2YN4P-20210513100818

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608840
Report Date: 05/07/2021
Date Signed: 05/07/2021 09:01:23 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
10/22/2020 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20201022100840

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: 39	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	05:04 PM
MET WITH:	Patria Dufrene, Administrator		TIME COMPLETED:	07:45 PM

ALLEGATION(S):

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Caregivers not assisting resident with ADL's.
Caregivers not treating resident with dignity.
Facility did not ensure resident had medical supplies.
Facility does not have call system.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint tele-visit investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with Patria Dufrene, Administrator.

The investigation consisted of the following: On 10/29/2021, LPA Almaraz conducted interviews with Administrator, Staff #1-3 and Residents #1-6 and attempted to interview Resident #7 but was no longer living at the facility. LPA requested copies of: Staff and Resident Roster, Staff #1-3 records, including training records, Resident #1-7 files and Incident Reports.

The investigation revealed the following: (Continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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-20201022100840

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: 05/07/2021

NARRATIVE

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Allegation "Caregivers not assisting resident with ADL's," it was alleged caregivers do not assist residents with changing, bathing or eating. Based on interviews conducted with staff and residents, they are all assisted and helped. All resident interviews conducted stated they have never been denied anything and are assisted during meals, bathing and changing. All staff interviews revealed they have not seen or been told a resident was not receiving assistance.

Allegation "Caregivers not treating resident with dignity," it was alleged staff members at the facility were cussing and calling a resident names. Based on interviews conducted with residents, all residents stated they are treated with dignity and have been not mistreated by any of the staff. Interviews with staff also revealed they have not seen or heard any staff or themselves call a resident names or cuss at them.

Allegation "Facility did not ensure resident had medical supplies," it was alleged a resident did not have enough bags in stock to replace residents colostomy bag. Interviews conducted revealed the resident was running low on colostomy bags but never went without any bags being in stock at the facility. Interviews with staff revealed the facility at one point had 4 bags in stock and they picked up more bags the following day.

Allegation "Facility does not have call system," it was alleged the facility did not have a call system and residents have to yell to get assistance. Based on interviews conducted and facility virtual walk through the facility has a call system in place. All interviews conducted with residents stated they have a call button and works.

Based on LPA's interviews conducted and records reviewed, investigation revealed: 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.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted via telephone with the Administrator and a hardcopy was provided via email for signature. Signatures on hardcopy.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
10/22/2020 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20201022100840

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: 39	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	05:04 PM
MET WITH:	Patria Dufrene, Administrator		TIME COMPLETED:	07:45 PM

ALLEGATION(S):

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Staff are not properly trained.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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 5

Control Number 28-AS-20201022100840

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: 05/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/14/2021 Section Cited CCR 87621(b)(1)(B)	1 2 3 4 5 6 7	Colostomy/Ileostomy:(b) In addition to Section 87611(b), the licensees shall be responsible for the following: (1) Ensuring that ostomy care is provided by an appropriately skilled professional. (B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of facility staff who have been instructed.	1 2 3 4 5 6 7	Assistant Administrator agrees to ensure that the ostomy bag and adhesive is changed by facility staff who have been instructed by an appropriately skilled professional.That there shall be documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of facility staff
	8 9 10 11 12 13 14	This deficiency was evidenced by the following: It was confirmed R7 had a colostomy bag and staff confirmed they care for the colostomy. Based on interviews conducted there was no written documentation outlining the instructions of procedures delagated and names of facility staff who were instructed.	8 9 10 11 12 13 14	who have been instructed. The professional shall review the procedures and techniques no less than twice a month and document the review in writing. Administrator will send LPA a written statement to LPA that she has read section 87621 understands it and will abide by it. POC due date 5/14/21.
	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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20201022100840

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: 05/07/2021

NARRATIVE

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Staff interviews revealed they were trained by the Administrator days prior to the resident arriving but there was nothing written outlining their duties to change the bag. Per staff interviews, they watched other caregivers change the bag and that was part of their training.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

Deficiencies cited under California Code of Regulations Title 22

An exit Interview was conducted via telephone with the Administrator and a hardcopy was provided via email for signature. Appeal Rights was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

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