197608840-11-1-2021-28-AS-CYEE-C9C7DH-20211202203422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608840
Report Date: 11/01/2021
Date Signed: 11/01/2021 04:01:03 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
10/29/2021 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211029124346

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: 42	DATE:	11/01/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Patria Dufrenne		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not screening visitors for COVID-19 symptoms prior to entering facility.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Patria Dufrenne/ House Manager Jennifer Rivas and explained the reason for the visit.

The investigation consisted of: On 11/01/21, LPA Gonzalez conducted interviews with the following facility staff: Administrator Patria Dufrenne, and House Manager Jennifer Rivas. LPA collected copies of Staff and Resident Rosters and Visitor Sign-In Sheets dated 10/1/21 - 11/1/21. LPA also reviewed facility Mitigation Plan.

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

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 3

Control Number 28-AS-20211029124346

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: 11/01/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following: Regarding allegation, Staff are not screening visitors for COVID-19 symptoms prior to entering facility, it is alleged that facility staff did not conduct COVID-19 screening on two separate occasions. Facility House Manager was allegedly educated on the importance of screening visitors upon entry to the facility on 8/9/21 and subsequently did not screen the same visitor on a follow up visit conducted on 10/4/21. Interview conducted with House Manager Jennifer Rivas revealed that facility staff are following COVID-19 guidelines and do screen visitors at all times. She stated that visitors have to sign in and their temperatures are taken and logged upon entry. She stated that there is usually a staff sitting in the lobby area to conduct COVID-19 screening and takes the temperatures of all incoming visitors. She stated that the facility also has extra masks to provide to visitors that walk in without a mask and they have the thermometer there to take all visitor's temperature upon sign in. She stated that when there is not an available staff to sit in the lobby area to screen visitors she conducts the screening process as she keeps the office door open and has a visual to the facility main entry door. House manager stated that she recalls not screening LTCO (Long Term Care Ombudsman) representative on 10/4/21 but does not recall being educated on the importance of screening visitors upon entry to the facility on 8/9/21.
Interview conducted with Administrator Patria Dufrenne revealed that facility is following COVID-19 guidelines at all times and stated that facility will now also ensure that facility staff are all aware that all visitors including visitors from government or local state agencies are also screened as well as their temperatures taken. Facility will continue to keep a visitor sign-in sheet/ log with record of visitors temperatures.

On 11/1/21, LPA Gonzalez was screened and temperature was taken by House Manager Jennifer Rivas upon entry into the facility. LPA reviewed facility mitigation plan and observed that mitigation plan states that anyone entering the facility signs in and has their temperature taken as well as symptoms checked and anyone entering the facility is required to wear a mask inside at all times. LPA observed all staff wearing masks. LPA reviewed visitor sign-in sheets and observed that the temperature of some visitors was not logged or recorded.

Based on interview conducted with facility staff and LPA review documents and observations, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22.

Exit interview was conducted with Administrator Patria Dufrenne. A copy of the report and appeal rights were provided to Administrator.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20211029124346

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: 11/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/02/2021 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter: Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California	1 2 3 4 5 6 7	Administrator agreed to ensure that facility is following California Dept of Public Health and CCLD requirements. Administrator will submit proof of staff re-training in COVID-19 infection control requirements, and will maintain a safe and healthful environment for residents and staff.
	8 9 10 11 12 13 14	This requirement was not met by evidence of: House Manager stated that LTCO representative was not screened on 10/4/21. On 11/1/21, LPA reviewed visitor sign in log and observed that some visitors temperature was not logged per COVID-19 Infection control recommendation. This poses an immediate health and safety risk to 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) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3