197609048-6-3-2020-11-AS-MCAA-BSZUXY-20200831155904

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609048
Report Date: 06/03/2020
Date Signed: 06/03/2020 01:01:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/12/2020 and conducted by Evaluator Jade Jordan

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200512105153

FACILITY NAME:	BEVERLYWOOD RETIREMENT HOME		FACILITY NUMBER:	197609048
ADMINISTRATOR:	KALISTRATOV, SERGUEI		FACILITY TYPE:	740
ADDRESS:	9014-9016 HARGIS STREET		TELEPHONE:	(310) 739-6178
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	6	CENSUS:	DATE:	06/03/2020
		UNANNOUNCED	TIME BEGAN:	11:27 AM
MET WITH:			TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Residents Needs Not Met During Fire Drill
Staff Mishandled Residents Personal Belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jade Jordan conducted a continuation of an unannounced 10-day complaint Tele-visit, to deliver findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Serguei Kalistratov.

LPA explained the purpose of today’s call is to complete and deliver findings for the above-mentioned allegations. “Residents Needs Not met during Fire Drill, Staff Mishandled Residents Belongings.”
The investigation consisted of the following: virtual tour via FaceTime of the inside of the facility and the outside grounds, Interview with the Administrator, Staff #1-2 and Residents #1-5. Review of Residents records, Tour of Residents bedroom. LPA Jordan obtained copies of all documents reviewed.

(REPORT CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020

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-20200512105153

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLYWOOD RETIREMENT HOME	FACILITY NUMBER: 197609048
	VISIT DATE: 06/03/2020

NARRATIVE

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The investigation revealed the following:

Regarding allegation: Residents Needs Not Met During Fire Drill

Based on interviews with Staff #1-2 (S1-S2), facility staff generally stated that they have never witnessed the fire department come out to the place of business on a false alarm called by a resident. Staff are aware that in case of an emergency staff are to meet outside with all residents. Staff stated that smoke alarms are tested often.

Based on interviews with Residents#1-5 (R1-R5), Resident generally stated that they have not witnessed any false fire alarms, where the fire department had arrived in error. Resident generally stated that they enjoy living at the facility, have no basic concerns at this time.

Based on LPA Jordan’s observations, records review, (Resident’s needs and services plan, admission agreement, Evacuation plan, Fire drill log ),virtual tour of the facility, and the interviews that were conducted. Therefore; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

Regarding allegation – Staff Mishandled Residents Personal Belongings.

The Administrator stated that due to the Corona virus Pandemic no outside visitors, besides designated staff, or medical personnel are being allowed to enter the facility, to lower the risk of current residents in care. Recently, one of the residents in care passed away in the hospital. The Administrator did not allow residents family to enter the facility to pack up the deceased residents’ personal belongings. The administrator and staff boxed and packed up residents’ personal things and placed them outside in the backyard for family to retrieve. According to Interviews with Residents in care they do not feel staff has mishandled their personal belongings.

Based on LPA Jordan’s observations, and virtual tour of the facility, record review (Resident’s needs and services plan, admission agreement, physicians reports), and the interviews that were conducted. Therefore; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted, and copy of this report was furnished to Administrator

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020

LIC9099 (FAS) - (06/04)

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