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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609367
Report Date: 12/20/2022
Date Signed: 12/20/2022 05:02:07 PM

Unsubstantiated


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
12/16/2022 and conducted by Evaluator Antonia Alvizar
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221216140503
FACILITY NAME:SANTA MONICA HOME & CARE 4FACILITY NUMBER:
197609367
ADMINISTRATOR:GARY STRATHEARNFACILITY TYPE:
740
ADDRESS:910 10TH ST UNIT ATELEPHONE:
(310) 576-0044
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:4CENSUS: 2DATE:
12/20/2022
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Administrators, Gary Strathearn and Jennifer BlockTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff do not ensure that COVID safety practices are being followed
Staff did not ensure resident has personal privacy in accommodations
INVESTIGATION FINDINGS:
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On 12/20/22 Licensing Program Analyst (LPA) Antonia Alvizar conducted an initial an unannounced complaint visit at this facility. LPA was greeted by Administrators Gary Strathearn and Jennifer Block. LPA explained the purpose of today's visit.

The investigation consisted of the following: LPA Alvizar obtained the following documents Personnel Report, Resident Roster, Residents #1-2’s Admissions Agreements, Physician Report, ID and Emergency Information, and Unusual Incident Report for R#1. LPA conducted Interviews with administrators, residents #1- #2 (R1-R2), Staff #1- #6 (S1-S6) and witness #1-#2 (W1 – W2). LPA Alvizar and Administrator Jennifer toured the facility physical plant.

Evaluation Report continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
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 2
Control Number 11-AS-20221216140503
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: SANTA MONICA HOME & CARE 4
FACILITY NUMBER: 197609367
VISIT DATE: 12/20/2022
NARRATIVE
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Continuation from LIC 9099

Regarding the allegation “Staff do not ensure that COVID safety practices are being followed.” During interviews conducted, 0 out of 3 residents agreed with the allegation. 0 out of 3 residents disagreed with the allegation, resident R2 stated “I don’t know, I think the staff are good.” Due to resident’s medical diagnosed they are unable to provide an answer. 4 out of 4 staff interviewed disagreed with the allegation staff S1 stated, “No, we follow all the stuff in our plan we clean and wear full gear, mask, gown, gloves when there is a positive COVID in the facility.” 0 out of 2 witnesses agreed with the allegation. 2 out of 2 witnesses disagree with the allegation witness #1 stated, “No, staff make sure they practice COVID safety”.“Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”


Regarding the allegation “Staff did not ensure resident has personal privacy in accommodations.” During interviews conducted, 0 out of 3 residents agreed with the allegation. 0 out of 3 residents disagreed with the allegation, resident R2 stated “No, they do allow privacy.” Due to resident’s medical diagnosed they are unable to provide an answer. 4 out of 4 staff interviewed disagreed with the allegation staff S3 stated, “No, resident’s have their own privacy we bring everything to their room when residents have COVID.” 0 out of 2 witnesses agreed with the allegation. 2 out of 2 witnesses disagree with the allegation witness #1 stated, “No, they have plenty of privacy they have their own room.” “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”


A copy of the Complaint Investigation Report was provided to Administrator, Jennifer Block. An exit interview was conducted.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2