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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608888
Report Date: 02/09/2024
Date Signed: 02/09/2024 03:25:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2024 and conducted by Evaluator Regina Cloyd
COMPLAINT CONTROL NUMBER: 11-AS-20240207092001
FACILITY NAME:WEST PICO TERRACE ASSISTED LIVING CENTER LPFACILITY NUMBER:
197608888
ADMINISTRATOR:CHRISTOPHER,MELISSAFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 84DATE:
02/09/2024
UNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Administrator Aaron MayesTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility doors in disrepair.
INVESTIGATION FINDINGS:
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On 02/09/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Health and Wellness Director Robin Owens and explained the purpose of the visit. Administrator Aaron Mayes arrived 20 minutes later.

The investigation consisted of the following: During today’s investigation, LPA toured the perimeters of the facility which included the front entrance, front emergency exit, outdoor patio, and garage area. LPA also interviewed 8 out of 84 residents and 8 staff which included the Administrator, Health and Wellness Director, MedTech, Payroll Representative, Maintenance and (3) caregivers. LPA also reviewed the resident records.

Continue to LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
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 11-AS-20240207092001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP
FACILITY NUMBER: 197608888
VISIT DATE: 02/09/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation "Facility doors in disrepair," interviews conducted indicated the following: three out of eight residents interviewed agreed with the allegations and five out of eight residents were unaware of a damaged door. During the facility tour, LPA noticed three doors that were in disrepair and one open garage gate. The first door is down the stairs near the second-floor lobby. The second door is down the stairs near the skilled nursing area. The third door is outside near the smoking patio. LPA also observed two residents reaching through the outside fence screening to open the door from the inside. Regarding the allegation “Facility doors in disrepair," based on interviews and observation, the preponderance of evidence has been met therefore the allegation is Substantiated.

Deficiencies were issued. An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed and left with Administrator Aaron Mayes.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20240207092001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP
FACILITY NUMBER: 197608888
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2024
Section Cited
CCR
87303(a)
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The facility shall be...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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The administrator will provide evidence that the damaged doors and garage gate were repaired. The administrator will also provide a written plan for ensuring the safety of the residents in care. Evidence and plan should be emailed to regina.cloyd@dss.ca.gov by the POC due date.
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Based on interviews and observations, the facility has three damaged doors and one damaged garage gate which poses a safety risk to the residents in care.
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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: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2024 and conducted by Evaluator Regina Cloyd
COMPLAINT CONTROL NUMBER: 11-AS-20240207092001

FACILITY NAME:WEST PICO TERRACE ASSISTED LIVING CENTER LPFACILITY NUMBER:
197608888
ADMINISTRATOR:CHRISTOPHER,MELISSAFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 84DATE:
02/09/2024
UNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Administrator Aaron MayesTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff are not safeguarding residents' belongings.
INVESTIGATION FINDINGS:
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On 02/09/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Health and Wellness Director Robin Owens and explained the purpose of the visit. Administrator Aaron Mayes arrived 20 minutes later.

The investigation consisted of the following: During today’s LPA toured the perimeters of the facility which included the front entrance, front emergency exit, outdoor patio, and garage area. LPA also interviewed 8 out of 84 residents and 8 staff which included the Administrator, Health and Wellness Director, MedTech, Payroll Representative, Maintenance and (3) caregivers. LPA also reviewed the resident records.

Continue to LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20240207092001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP
FACILITY NUMBER: 197608888
VISIT DATE: 02/09/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation “Staff are not safeguarding residents' belongings," interviews conducted indicated the following: seven out of eight residents interviewed had not heard about residents’ belongings being stolen. Eight out of eight staff members have not heard about residents’ belongings being stolen. Record reviews indicate that eight out of eight residents have theft and loss policy on file. Based on the interviews and record reviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.


No deficiencies were cited. An exit interview was conducted and technical assistance provided. A copy of this report was reviewed and left with Administrator Aaron Mayes
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5