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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608888
Report Date: 08/25/2023
Date Signed: 02/09/2024 11:41:51 AM

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
08/10/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230810095405
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: 71DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:ADMINISTRATOR MELLISA CHRISTOPHERTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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FACILITY HAS PESTS
INVESTIGATION FINDINGS:
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THIS REPORT SUPERSEDES THE REPORT DATED 08/25/2023 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 08/16/2023 and was greeted by Manager Aaron Mays (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 allegations.
During this investigation, LPA Calderon interviewed Administrator (A1), Staff (S1), Residents (R1-R8). This interview was conducted on 08/16/2023. On 08/16/2023 LPA Calderon requested copies of the following: Physician’s report (06/14/2023), needs and service plan (07/13/2023) for R1, incontinence training, pest control report (March, May 2023).
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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-20230810095405
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: 08/25/2023
NARRATIVE
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Regarding Allegation #1: Facility has pest.

This complaint alleged that the facility has roaches. LPA Calderon interviewed (A1). (A1) acknowledged that the facility does have roaches. (A1) explained that pest control sprays monthly for pests. (A1) reported that residents and staff are allowed to report pests to (A1), and (A1) will order staff to spray or have pest control spray on the affected area. LPA Calderon interviewed (S1). (S1) described that before COVID 19 there were no pest issues. (S1) stated that since residents are allowed to eat their meals in their rooms the facility had pest problems. (S1) reported that staff and pest control company spray pests weekly, and or as needed. (S1) stated that since the dining policy changed back to the dining room the pest problems have improved. LPA Calderon interviewed with (R1). (R1) explained that there are roaches throughout the facility and roaches inside (R1’s) room. LPA Calderon interviewed with resident #2-#8 (R2-R8). R2, R4, R6, and R7-R8 reported that they had observed roaches in the dining room, hallways, and in


their rooms. (R3), and (R5) communicated that they have not seen any roaches inside their rooms or throughout the facility. On 08/16/2023 LPA Calderon and (A1) toured all common areas including the dining room, kitchen, and rooms #205, #210, #218, and #307. Pests were found in the bathrooms of rooms #210 and #307.

On 08/16/2023 LPA Calderon reviewed pest control reports for March and May 2023. Pest control services were not found.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation that the Facility has pest 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 Manager Aaron Mayes.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20230810095405
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: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
CCR
87307(a)
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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. This requirement is not met as evidenced by:
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Administrator will have pest control spray the affected rooms and provide LPA Calderon pest control reports monthly as to progress in taking care of roach issues.
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Based on interview, observation, and record review, the licensee failed to ensure that the facility is safe and healthful for residents in care as result roaches were found in room #210 and #307 which poses a health risk 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: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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, 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
08/10/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230810095405

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: 71DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:ADMINISTRATOR MELLISA CHRISTOPHERTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff do not meet resident's incontinence needs
Staff do not allow resident to have possession of their personal belonging
Staff did not safeguard resident's personal belonging
INVESTIGATION FINDINGS:
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THIS REPORT SUPERSEDES THE REPORT DATED 08/25/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: UNSUBSTANTIATED
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the West Pico Terrace Assisted Living Center facility on 08/16/2023 and was greeted by Manager Aaron Mays (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 allegations.
During this investigation, LPA Calderon interviewed Administrator (A1), Staff (S1), Residents (R1-R8). This interview was conducted on 08/16/2023. On 08/16/2023 LPA Calderon requested copies of the following: Physician’s report (06/14/2023), needs and service plan (07/13/2023) for R1, incontinence training, pest control report (March, May 2023).
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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-20230810095405
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: 08/25/2023
NARRATIVE
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Regarding Allegation #1: Staff do not meet residents’ incontinence needs.

This complaint alleged that staff did not change R1’s diaper at night. LPA Calderon interviewed (A1). (A1) affirmed that staff does change (R1) diapers at night as well as resident that require a diaper change is taken care of by staff. LPA Calderon conducted an interview with (S1). (S1) expressed that the night staff changes the diapers of (R1) and any other resident that needs incontinence services. (S1) reported that staff do not keep records of the diaper changes, but if interviews with the night staff, the staff will confirm that diaper changes were performed. On 08/16/2023, LPA Calderon attempted to interview (R1) for complaint. Due to (R1’s) health condition, (R1) is unable answer any questions. LPA Calderon interview residents #2-#8 (R2-R8). (R2) verified that (R1) uses diapers, and staff does assist (R1) with diaper changes. (R3) claimed to use diapers and that staff assisted with diapers changes daily. (R4-R8) reported they do not use diapers themselves and unaware of residents that use diapers. (R2-R8) claimed that any resident that uses diapers is assisted by staff as required. On 08/16/2023, LPA Calderon reviewed (R1’s) Physician report and the Needs and Service Plan (06/14/2023) and (07/13/2023). Records revealed (R1) has a health condition and required assistance with incontinence care.Regarding Allegation #2: Staff do not allow residents to have possession of their personal belongings.This complaint alleged that staff had taken a used piano away from R1. LPA Calderon interviewed (A1). (A1) expressed that the (R1) purchased a used piano and stored the piano in (R1’s) room. (A1) stated that months later (R1) was getting a roommate (R2) to occupy the shared room. (A1) reported that there was no room to accommodate a piano and that it was moved to the dining room area. (A1) claimed that (R1) was given notice before the piano was moved. LPA Calderon interviewed (S1). (S1) stated that staff were aware of (R1’s) piano purchase and the musical instrument had to be relocated, due to (R2) occupying the shared room with no room for a musical instrument. (R2) required agility assistance with a wheelchair and mobility devices need space for mobility.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20230810095405
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: 08/25/2023
NARRATIVE
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(S1) stated that (R1) requested to be moved to another room. (R1) was notified of the piano relocation and was given dates and times (R1) could play the piano in the dining room area. LPA Calderon interviewed (R1). (R1) claimed to have purchased a used piano and it was housed in (R1’s) room. (R1) verified that (R2) moved into the shared room and staff eventually had to move the piano into the dining room. (R1) claimed that no staff notified (R1) that the piano had to be relocated.
LPA Calderon interviewed (7) out of (8) residents #2-#8 (R2-R8) and reported that staff have never taken a personal item out of their rooms without permission. (R2), and (R4-R8) communicated that they are aware that (R1) purchased a piano. (R2), (R4-R8) claimed that staff moved the piano as (R2) occupied the shared room with (R1). There was no room for (R2’s) personal belongings and to accommodate (R1’s) piano. (R2), and (R4-R8) stated they observed (R1) playing the piano in the dining room area. (R3) reported having no knowledge of a resident purchasing a piano but (R3) has witnessed (R1) playing a piano. On 08/16/2023, LPA Calderon and A1 toured the facility. LPA Calderon inspected room 205 and identified the dining room where the piano is located. LPA Calderon observed that there is no room for a piano to be relocated in room #205 and still be able to provide adequate mobility space for (R2’s) wheelchair use.
Regarding Allegation #3: Staff did not safeguard residents personal belonging.This complaint alleged that staff had taken, lost, or misplaced a computer R1 purchased. LPA Calderon interviewed with (A1). (A1) explained that the prior administrator no longer works for the facility and (A1) has no knowledge of a computer that was purchased by an (R1). (A1) reported (R1) does not have a computer nor know (R1’s) computer whereabouts. LPA Calderon interviewed with (S1). (S1) stated that the staff safeguards all resident's property and (S1) does not know what happened to the (R1’s) computer. LPA Calderon interviewed (R1). (R1) claimed that (R1) purchased a computer. (R1) realized that (R1) could not afford the computer and tried to cancel the purchase, but the computer arrived by mail. (R1) claimed that (R1) did not open the computer box and asked the administrator Vladimir Kaplum to help (R1) return the computer. (R1) explained that the administrator never returned the computer, and the computer has gone missing and (R1) is now charged for the purchased. LPA Calderon interviewed (8) out (8) residents #2-#8 (R2-R8) reported that no staff has taken, or stolen any of their personal property, and while (7) out of (8) residents stated to have no knowledge of any resident purchasing a computer nor any staff taking a computer or not safeguarding the property of a resident.

LPA reached out to the former administrator for a statement by telephone was not available for an interview. The contact number on record was no longer available.



Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of Staff does not meet residents’ incontinence needs, staff do not allow residents to have possession of their personal belongings, staff did not safeguard residents personal belonging is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Manager Aaron Mays.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6