197609311-4-17-2025-11-AS-UCOL-DFUPRA-20250418113225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609311
Report Date: 04/17/2025
Date Signed: 04/17/2025 08:36:28 AM

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
04/25/2024 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20240425155135

FACILITY NAME:	WATERMARK AT BEVERLY HILLS, THE		FACILITY NUMBER:	197609311
ADMINISTRATOR:	JAMES HOWLAND		FACILITY TYPE:	740
ADDRESS:	220 N CLARK DRIVE		TELEPHONE:	(310) 860-9234
CITY:	BEVERLY HILLS	STATE: CA	ZIP CODE:	90211
CAPACITY:	75	CENSUS: 49	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	DIRECTOR JAMES HOWLAND		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

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Resident developed a stage 3 pressure injury while in care.
Staff are not following resident's doctor's medication orders.
Facility is operating beyond the scope of the license.

INVESTIGATION FINDINGS:

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On 04/17/2025 Community Care Licensing Division (CCLD) staff conducted an unannounced visit to Watermark at Beverly Hills facility and met with Director Jim Howland (S1). The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
The investigation consisted of the following: Licensing Program Analyst (LPA) Jose Calderon interviewed Director S1, Staff S1-S5, Resident R1-R6. LPA Calderon obtained and reviewed the following: Physician Report (dated 12/14/2023), Special Instructions (dated 04/29/2024), Watermark Assessment (dated 04/07/2024), Medication Administration Record (MAR) (dated 03/2024 to April 2024), Incident reports (dated 01/05/2024 to 04/27/2024), Golden Seasons hospice plan of care (dated 04/14/2024) for R1. Physician Report (dated 09/07/2022), MAR (dated November to December 2023), Golden Seasons Hospice (dated 11/08/2023), Golden Seasons hospice staff sign in sheet (dated 11/2023 to 04/2024), Golden Seasons hospice patient calendar (dated 11/2023 to 04/2024), Hospice plan of care (dated 04/09/2024) for R6. Reviewed approved hospice waiver for 6 residents (dated 05/11/2012), Reviewed assisted living 24-hour report (dated 05/28/2024) for R1 and R6.

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: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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 3

Control Number 11-AS-20240425155135

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: WATERMARK AT BEVERLY HILLS, THE	FACILITY NUMBER: 197609311
	VISIT DATE: 04/17/2025

NARRATIVE

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The investigation revealed the following: Regarding the Allegation: Resident developed a stage 3 pressure injury while in care. It is being alleged that R1 developed a prohibited health condition while in care. During the investigation LPA Calderon observed the hospice nurse providing hospice care to R1. Record reviews indicate the following. Based on the facility’s records assisted living 24-hour report (dated 05/28/2024), noted hospice services provided to R1. R1’s hospice plan of care dated 09/23/2023 indicate that R1 was diagnosed with end stage disease, and R1 had risk for skin breakdown due to end stage disease process. R1’s hospice care plan dated 12/27/2023 indicated plans for wound care interventions were developed to address R1’s stage 3 pressure injury. Interviews conducted indicates the following: 5 out of 5 staff did not agree with the allegation. R1 could not answer any questions due to health issues. 5 out of 6 residents indicate that residents have not developed a pressure injury while in care. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “resident developed a stage 3 pressure injury while in care” is found to be UNSUBSTANTIATED.

Regarding the Allegation: Staff are not following residents’ doctors’ medication orders. It is being alleged that the facility administered medications at higher dosage compared to doctors’ orders. LPA Calderon inspected the facility with S1 and noted staff using electronic MAR when giving prescribed medications to residents in care. LPA Calderon entered the Med Tech room and noted staff using the electronic MAR system and getting ready to pass out prescribed medications to residents in care. Med Tech staff explained the medication process using the electronic MAR system and indicate that it is very hard for a medication error to be made by staff using the electronic MAR system. Facility staff indicate that when medication is given to a resident the MAR system advises staff what medication is prescribed and the dosage amount. LPA Calderon reviewed the Medication Administration Record (MAR) for R1 and R6 dated 03/2024 to April 2024, no medication errors were noted. 5 out of 5 staff denied the allegation. R1 could not answer any questions due to health issues. 5 out of 6 residents indicates that there are no issues with staff following doctor medication orders. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are not following residents’ doctors’ medication orders” is found to be UNSUBSTANTIATED.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240425155135

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: WATERMARK AT BEVERLY HILLS, THE	FACILITY NUMBER: 197609311
	VISIT DATE: 04/17/2025

NARRATIVE

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Regarding Allegation: Facility is operating beyond the scope of the license. It is being alleged that non-medical professional staff are treating R1’s stage 3 pressure injuries. LPA Calderon toured the facility with S1. During the investigation LPA Calderon observed the hospice nurse providing hospice care to R1. Reviewed hospice plan of care (dated 04/14/2024) for R1 and R6 (dated 04/09/2024). Hospice Care plan indicates that Golden Seasons hospice care nurse is taking care of stage 3 wound care needs for R1. LPA Calderon reviewed the Golden Seasons Hospice patient calendar (dated 11/2023 to 04/2024) noted Golden Seasons hospice nurse visit frequency 2 times per week. 5 out of 5 staff deny the allegation. R1 could not answer any questions due to health issues. 5 out of 6 residents do not have any knowledge of staff treating any resident beyond the scope of the license. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “facility is operating beyond the scope of the license” is found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit.

An exit interview was conducted, and a copy of the Complaint Report were provided to the Director Jim Howland (S1).

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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