197802563-9-11-2020-28-AS-WSHO-BUD42K-20201013184314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802563
Report Date: 09/11/2020
Date Signed: 09/11/2020 05:12:56 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/28/2020 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200828111008

FACILITY NAME:	EL DESCANSO RETIREMENT HOME		FACILITY NUMBER:	197802563
ADMINISTRATOR:	BOUSHERI, CLEMENCIA		FACILITY TYPE:	740
ADDRESS:	21020 E. CIENEGA AVENUE		TELEPHONE:	(626) 967-2868
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	15	CENSUS: 12	DATE:	09/11/2020
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Clemencia Bousheri, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility denying resident medical attention.
Facility is not providing 3 meals per day on a regular basis.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza initiated a subsequent complaint investigation to deliver findings on the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Clemencia Bousheri.

The investigation consisted of the following: On 9/2/20, LPA initiated a virtual 10-day complaint visit; which included a physical plant tour via FaceTime. Residents (R1- R5), and staff (S1-S5) were interviewed. Six (6) were not interviewed due to cognitive deficits. Resident (R1) file documents were obtained: [Identification and Emergency Information, Physician Report, Resident Appraisal, RCFE Levels of Care Assessment Tool, Functional Capability Assessment, Power of Attorney info, Medication report, Admission agreement, LIC 500 Personnel Report, resident roster, and keekly food menu. On 9/3/20, R1's Power of Attorney was interviewed; receipts of daily food delivery for August 2020 via Uber Eats, and Postmates were provided.

See LIC 9099C - for continuation of report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020

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 28-AS-20200828111008

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EL DESCANSO RETIREMENT HOME	FACILITY NUMBER: 197802563
	VISIT DATE: 09/11/2020

NARRATIVE

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Allegation: "Facility denying resident medical attention." Based on interviews conducted the findings indicate facility does not deny residents medical attention. Resident (R1) informed staff that it needed medical attention, due to shortness of breath. 911 Emergency services responded, and found R1 to be stable; not in need of medical attention. Per staff protocol they are instructed to immediately call 911, and notify the resident's MD to obtain guidance/instructions during emergencies. All staff denied negligence in care, and stated that all residents receive medical attention when needed. Resident (R1) stated that staff did call 911, but hospitalization was not needed. R1's Power of Attorney was notified of 911 incident call in late August 2020, but medical personnel deemed R1 stable, and not in need of medical attention. Five (5) out 5 residents, and five (5) staff interviewed denied allegation.

Allegation: "Facility is not providing 3 meals per day on a regular basis." Based on observations during physical plant inspection, and interviews conducted there is not supporting evidence to prove the allegation. LPA observed 4 large size refrigerators, and pantry area in the home. The facility had a surplus of perishable, and non-perishable food items. Residents did not appear to have malnutrition. All residents interviewed stated they are fed daily. Resident (R1) denied allegation, and stated that staff offer resident all daily meals, but declines to eat the facility food because of dislike of cooked food items. R1 stated that family member/Power of Attorney arranges fast food delivery services; therefore eats 80% of meals through food delivery services "Uber Eats" and "Post Mates". R1 prefers to eat fast food items, and stated "I am a picky eater."

Based upon document review and interviews conducted the findings indicate that, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

A telephonic exit interview was conducted with Administrator Clemencia Bousheri. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA. Administrator stated that signed copies will be emailed on 9/14/20.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020

LIC9099 (FAS) - (06/04)

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