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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608888
Report Date: 01/06/2024
Date Signed: 01/06/2024 10:05:02 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20231101092846
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: 78DATE:
01/06/2024
UNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Melanie Heard-RCCTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff do not answer residents' call buttons in a timely manner
INVESTIGATION FINDINGS:
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On 1/6/2024 at 9:30 AM Licensing Program Analyst (LPA) Alfonso Iniguez conducted a subsequent complaint visit to deliver the complaint findings. Upon arrival, LPA Montoya met with Administrator Aaron Mayes and LPA explained the purpose of this visit.

The investigation consisted of the following: On 11/8/2023, LPA Lourdes Montoya toured the facility with Health and Wellness Director Robin Owens. LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. LPA attempted to interview two other residents who refused the interview. LPA requested and obtained copies of Staff roster, Resident roster, and one resident's (R1) service records (Admission Agreement, Physician's Reports and Appraisals/Needs and Services Plans). LPA also requested other pertinent records.

Report continued in LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
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 6
Control Number 11-AS-20231101092846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP
FACILITY NUMBER: 197608888
VISIT DATE: 01/06/2024
NARRATIVE
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Investigation revealed the following:

Allegation: Staff do not answer residents' call buttons in a timely manner.

It was alleged that staff do not answer residents' call buttons in a timely manner. On 11/8/2023 between 11:55 am – 2:05 pm, LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. Based on interviews conducted, 3 out of 5 staff (S1, S2, S4) stated the resident’s call button should be answered between 5-10 minutes for a timely response. S1 and S2 stated beyond 10 minutes is unacceptable. S5 stated the usual wait for a resident’s call is between 5-15 minutes while S3 revealed residents usually wait for 5-30 minutes. Based on interviews conducted, 4 out of 6 residents (R2, R3, R4, and R6) admitted they use the call button for help, and they wait between 5-45 minutes, 1 out of 6 (R1) residents stated the wait is up to an hour and 20 minutes. One resident (R5) has not used the call button to call for help. LPA did not obtain any records pertaining to call button incidents. Based on LPA’s observation on 11/8/2023 at around 1:03 PM while testing the call button in room #229B with S2, staff did not respond to the call button within 10 minutes. S2 aborted the test immediately after 10 minutes and called staff by using a walkie talkie. Per LPA’s observations, staff do not always answer residents’ call buttons in a timely manner. Based on information gathered, there is sufficient evidence to corroborate the above allegation.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of “Staff do not answer residents' call buttons in a timely manner” is found to be SUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to Melanie Heard/RCC
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20231101092846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP
FACILITY NUMBER: 197608888
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This was not met as evidenced by:
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POC:
Administrator shall review the cited section and shall self-certify understanding and compliance with the regulation. Administrator shall conduct an in-service training to staff on this regulation. POC shall be submitted to CCLD by faxing to 424-544-1016 by the POC due date.
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Based on LPA’s observations and interviews, four residents admitted they use the call button for help, and they wait between 5-45 minutes, while one resident stated the wait is up to an hour and 20 minutes. Two staff admitted the call button should be answered within 5-10 minutes, beyond that is unacceptable. Based on LPA’s observation on 11/8/2023 at around 1:03 PM while testing the call button in room #229B with S2, staff did not respond to the call button within 10 minutes. S2 aborted the test immediately after 10 minutes and called staff by using a walkie talkie. Per LPA’s observations, staff do not answer residents’ call buttons in a timely manner. This poses a potential risk to residents’ health, safety and/or personal rights to 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20231101092846

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: 78DATE:
01/06/2024
UNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Melanie Heard-RCCTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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9
Staff do not provide adequate food service to residents
Staff falsified resident documents
INVESTIGATION FINDINGS:
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On 1/6/2024 at 9:30 AM, Licensing Program Analyst (LPA) Alfonso INiguez conducted a subsequent complaint visit to deliver the complaint findings. Upon arrival, LPA Montoya met with Administrator Aaron Mayes and LPA explained the purpose of this visit.

The investigation consisted of the following: On 11/8/2023, LPA Lourdes Montoya toured the facility with Health and Wellness Director Robin Owens. LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. LPA attempted to interview two other residents who refused the interview. LPA requested and obtained copies of Staff roster, Resident roster, and one resident's (R1) service records (Admission Agreement, Physician's Reports and Appraisals/Needs and Services Plans). LPA also requested other pertinent records.

Report continued in LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
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 6
Control Number 11-AS-20231101092846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP
FACILITY NUMBER: 197608888
VISIT DATE: 01/06/2024
NARRATIVE
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Investigation revealed the following:

Allegation: Staff do not provide adequate food service to residents.

It was alleged that staff do not provide adequate food service to residents. On 11/8/2023 between 11:55 am – 2:05 pm, LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. Based on interviews conducted, 5 out of 5 staff and 5 out of 6 residents denied that staff do not provide adequate food service to residents. They revealed that meals are always served timely. S2 stated every meal has a set schedule both in the dining hall and in room service. Breakfast is ready between 8:00 am – 8:15 am, lunch (12:00 pm – 12:15 pm), and dinner (5:00 pm – 5:15 pm). R1 claimed food is sometimes delivered to the room late. Based on LPA’s record review and observation during the visit, the meals serving time posted in the dining hall is consistent with S2’s statements. LPA observed residents eating in the dining hall at 12:00 pm. LPA also observed a staff delivering a tray of a resident’s meal to bedroom # 229A at 12:11 pm which is within the facility’s meals serving time schedule. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Staff falsified resident documents.

It was alleged that staff falsified resident documents. On 11/8/2023 between 11:55 am – 2:05 pm, LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. Based on interviews conducted, 5 out of 5 staff and 5 out of 6 residents denied that staff falsified resident documents. R1 claimed R1’s contract has been changed many times and it is not signed by the facility administrator. S1 stated R1 owes the facility in back rent, and it was necessary to amend the contract with the agreement to pay the back rent until the account is current. Based on record review, R1’s lease addendum dated 11/1/2023 pertains to the payment for the back rent and it was signed by a facility representative and R1. During the investigation, LPA did not observe unusual activities by the facility falsifying resident documents. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20231101092846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP
FACILITY NUMBER: 197608888
VISIT DATE: 01/06/2024
NARRATIVE
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Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations, “Staff do not provide adequate food service to residents”, and “Staff falsified resident documents” are found to be UNSUBSTANTIATED.

Exit interview was conducted and a copy of the report was provided to Melanie Heard/CCR
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6