197608888-2-9-2024-11-AS-EMAZ-D2FUU9-20240214145306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608888
Report Date: 09/06/2023
Date Signed: 02/09/2024 12:01:30 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
08/30/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20230830093526

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: 67	DATE:	09/06/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	ADMINISTRATOR MELISSA CHRISTOPHER		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not ensuring that resident is fed while in care.

INVESTIGATION FINDINGS:

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THIS REPORT SUPERSEDES THE REPORT DATED 09/06/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: SUBSTANTIATED
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the West Pico Terrace Assisted Living Center facility on 09/06/2023 and was greeted by Administrator Melissa Christopher (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.
During this investigation, LPA Calderon interviewed Administrator (A1), Residents (R1-R7). This interview was conducted on 09/06/2023. On 09/06/2023 LPA Calderon requested copies of the following: Physician’s report (12/29/2022), needs and service plan (09/13/2022), Admission Agreement (09/13/2022) for R1. Admission Agreement for 2 other residents was reviewed.
The investigation revealed the following:

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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-20230830093526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP	FACILITY NUMBER: 197608888
	VISIT DATE: 09/06/2023

NARRATIVE

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Regarding Allegation #1: Staff are not ensuring that resident is fed while in care.This complaint alleges that the facility is charging five-dollar food tray fee for residents that do not eat in the dining room.LPA Calderon conducted an interview with A1. A1 expressed that with Covid19 being reduced the facility was going back to food services in the dining room. A1 expressed that if a resident for health condition was not able to go to the dining room staff will take food to resident’s room. A1 expressed that the additional five dollars per meal service tray was not in the admission agreement R1 or any other resident signed and nothing in writing was given to residents regarding the additional fees. A1 expressed that R1 was non-ambulatory and could not go to the dining room for meals and R1 was not charged the additional service tray fee. A1 states that staff delivered R1 food to R1 room and R1 was never charged the try service fee. A1 expressed that this new program just started in August 2023 and no resident has had to pay the additional tray service fee. LPA Calderon conducted an interview with R1. R1 expressed that R1 refused to pay the tray service fee of five dollars for a total of fifteen dollars per day. R1 expressed that the additional food tray fee was not in the admission agreement R1 signed and R1 made a complaint to A1. R1 expressed that R1 was not capable of going to the dining room due to health conditions and staff delivered food to R1 room. LPA Calderon interviewed 6 out of 7 clients #2-#7 (R2-R7) reported that residents heard of the new five-dollar room tray service fee for residents capable of eating in the dining room. Six out of seven residents have not paid any tray service fees to the facility. Six out of seven residents expressed that residents do not have the additional 15 dollars to pay the tray service fee and staff does deliver food to residents’ room. On 09/06/2023 LPA Calderon reviewed R1 admission agreement. LPA Calderon did not see any additional food tray service fees for residents not capable of eating their meals in the dining room. The admission agreement does provide for residents with health issues and not capable of going to the dining room. The agreement does state that staff does deliver food to residents that cannot eat in the dining room. LPA Calderon reviewed R1 needs and service plan and physician agreement. R1 has health condition and is non-ambulatory. R1 needs help getting out of bed into wheelchair. R1 meets the definition under the admission agreement section 3(b)(5)(17).Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of “staff are not ensuring that resident is fed while in care” is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiency has been observed and citations issued (ref LIC9099D).

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator (Melissa Christopher) A1.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230830093526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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: 09/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/15/2023 Section Cited CCR 85060(a)(3)	1 2 3 4 5 6 7	85060Basic Services (a) For SSI/SSP recipients who are residents...(3) An extra charge to the resident shall be allowed for provision of special food services or products beyond that specified in Section 80076(a)(2) and (a)(4) when the resident wishes to purchase the services and agrees to the extra charge in the admissions agreement. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide a new admission agreement with the additional 5 dollar food tray fee for room service or send written notice that additional fee will not longer be charged. Administator will refund any resident that has paid the service fee. Administrator will email new agreement to LPA Calderon by POC date.
	8 9 10 11 12 13 14	Based on interview, observation, and record review, the administrator failed to provide a new admission agreement with the aditional food service fees which poses a health 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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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