197609367-5-10-2024-11-AS-UCOL-D4MS7F-20240424133726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609367
Report Date: 12/05/2023
Date Signed: 05/10/2024 02:22:40 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, 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
11/27/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20231127151151

FACILITY NAME:	SANTA MONICA HOME & CARE 4		FACILITY NUMBER:	197609367
ADMINISTRATOR:	GARY STRATHEARN		FACILITY TYPE:	740
ADDRESS:	910 10TH ST UNIT A		TELEPHONE:	(310) 576-0044
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90403
CAPACITY:	4	CENSUS: 13	DATE:	12/05/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	ADMINISTRATOR GRAY STRATHEARN		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff interfered with a resident from having a visitor while in care

INVESTIGATION FINDINGS:

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This report supersedes the report dated 12/05/2023, the purpose of this amendment is to provide clarification on the circumstance surrounding the allegations. although this report supersedes the previous report the complaint investigation findings remain the same: Unsubstantiated.
On 12/05/2023 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit to Santa Monica Home and Care 4. LPA Calderon initiated an investigation into the above-mentioned allegation and conducted an interview with Administrator Gary Strathearn (A1).

The investigation consisted of the following: On 12/05/2023 LPA Calderon interviewed A1, staff S1 and S2, residents R1 through R4, and witnesses W1 and W2. LPA Calderon obtained and reviewed the following: Needs and Service Plan (dated 07/12/2021), Physician Report (dated 05/12/2021), Incident report (dated 11/22/2023), texted messages (dated 11/22/2023) and admission agreement (dated 08/24/2021) for R1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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-20231127151151

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SANTA MONICA HOME & CARE 4	FACILITY NUMBER: 197609367
	VISIT DATE: 12/05/2023

NARRATIVE

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The investigation revealed the following:

Regarding Allegation: “Staff interfered with a resident from having a visitor while in care.” This complaint alleged that the facility staff asked a private caregiver to leave the facility on 11/22/202. Interviews with staff indicate, that resident R1’s private caregiver W2 had an argument and yelled at staff S2 and W2 was asked to leave the facility as indicated on residents’ admission agreement. Staff added that W2 was allowed back into the facility and W2 continued to provide care for R1 on the same day. 4 out of 4 residents #1-#4 (R1-R4) unable to answer questions due to their health conditions. Witness interviews indicate the following: On 11/22/2023 W2 was allowed back into the facility to care for R1. Record reviews indicate: The incident report (dated 11/22/2023), indicated that a verbal disagreement between S2 and W2 happened regarding R1 sitting at the patio table and W2 yelled at S2. R1’s Needs and Services Plan indicate R1 is non-ambulatory and requires assistance from staff for overall care. Admission Agreement dated 08/24/2021, page 26 section 11, indicate that Santa Monica Home & Care (SMHC) has the right to refuse entry to any persons, including home health care agencies for cause, the cause will be potential harm, including physical, mental, or verbal abuse to residents or staff. Based on interviews and record reviews: the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is Unsubstantiated.

An exit interview was conducted, and a copy of the Complaint Report was provided to Administrator Gary Strathearn.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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