197608888-4-24-2024-11-AS-MVAO-D5VQ7B-20240603115448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608888
Report Date: 04/24/2024
Date Signed: 04/24/2024 04:17:40 PM

Unsubstantiated

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
04/16/2024 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20240416133420

FACILITY NAME:	WEST PICO TERRACE ASSISTED LIVING CENTER LP		FACILITY NUMBER:	197608888
ADMINISTRATOR:	CHRISTOPHER,MELISSA		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	136	CENSUS: 88	DATE:	04/24/2024
		UNANNOUNCED	TIME BEGAN:	10:09 AM
MET WITH:	ADMINISTRATOR CLARIZZE PUNIT		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff relocated resident from facility without consent.

INVESTIGATION FINDINGS:

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On 04/24/2024 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to West Pico Assisted Living Center facility and was greeted by Administrator Charizze Punit (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following: LPA Calderon interviewed Administrator A1, Staff S1-S2, Resident R1-R10, Witness W1. These interviews were conducted on 04/22/2024 and 04/24/2024. LPA Calderon obtained and reviewed the following: Veterans Administration VA/Physician Report (dated 12/12/2023), Needs and Service plan (dated 12/12/2023), Admission Agreement (Dated 12/18/2023), Public Guardian (PG) records (date 3/22/2024), email from VA (date 04/24/2024)

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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 11-AS-20240416133420

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: 04/24/2024

NARRATIVE

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Regarding Allegation: Staff relocated resident from facility without consent.

This complaint alleged that staff relocated R1 from facility without consent. A1 states that A1 received an email from prior administrator Aaron Mayes date 03/21/2024 regarding moving R1 to the new facility. A1 states that A1 started to communicate with the VA on 03/21/2024 and received authorization from the VA on 3/21/2024 and from the PG on 3/25/2024. A1 states that the decision to move the resident was made with the authorization from the VA, PG, and the resident. A1 states that the resident was moved to a smaller facility so that a one-to-one care plan could be given. 2 out of 2 staff state that any change to a resident care consent is requested prior to the change. R1 states that R1 did not know and did not give consent to the change in facilities. 9 out of 10 resident states that any change to care written consent is requested. W1 states that W1 was aware of the change in facilities and gave authorization on 03/25/2024. Reviewed the admission agreement for R1 (date 12/18/2023). The conservator is W1 who is also the PG for resident’s care. Reviewed the Physician report (date 12/12/2023), R1 has health issues and is conserved. Reviewed email from the VA and Four Seasons Assisted Living facility (date 03/22/2024). Appears there is communication between the VA, PG and the facility and authorization granted prior to the resident being moved to the new facility.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “staff relocated resident from facility without consent” is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Clarizze Punit (A1).

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

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