197802563-6-2-2022-28-AS-MVAO-CF8RU5-20220609131922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802563
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:58:01 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 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
11/02/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20211102102416

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: 10	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Escarling Godoy - Caregiver Clemencia Bousheri - Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff are physically abusive to resident.
Resident sustained injuries while in care.
Staff are not assisting resident with incontinence needs.
Staff are not assisting resident with transfers.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Escarling Godoy caregiver and explained the reason for the visit. Administrator Clemencia Bousheri arrived 15 minutes after.

The investigation consisted of the following: On 11/3/21 LPA Flores conducted a health and safety check of the facility which consisted of a tour of the facility with Geovanny Mora facility's caregiver no deficiencies were noted during the visit and requested a copy of the staff and resident roster. On 6/2/22 LPA Flores interviewed resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5), administrator, and staff,#2(S2),#3(S3),#4(S4),#5(S5) and requested copies of physician's report, identification and emergency information, appraisal needs and care plan for R1,R2,R3,R4,R5, nurse/caregiver notes for R1, trainings on incontinence care, transfer, personal rights and behaviors for the past year for S2,S3,S4,S5.

(CONTINUED ON LIC (9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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 3

Control Number 28-AS-20211102102416

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: 06/02/2022

NARRATIVE

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The investigation revealed the following: Regarding allegations: Staff are physically abusive to resident and resident sustained injuries while in care. It is alleged R1 is getting abused by the staff and has bruises on arms. On 11/3/21 LPA Flores conducted a tour of the facility and observed residents in care, R1 was observed in bed, arms and chest was visible no bruises were observed. Interviews with residents revealed 2 out of 5 residents stated staff are nice, helpful, and know how to care for them. 2 out of 5 residents were unable to answer due to cognitive skills, and 1 out of 5 residents stated staff has not left bruises when caring. Interviews with staff revealed 5 out of 5 staff stated staff are respectful to residents, have not observed bruises in residents arms, and have received training on personal rights. Documents reviewed revealed staff received training on resident's personal rights and a signed copy is maintain in the staff's file.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Regarding allegation: Staff are not assisting resident with incontinence needs. It is alleged resident "sits on pee and poo". Interviews with residents revealed 2 out of 5 residents stated to receive assistance with incontinence care, 1 out of the 2 stated to be assisted every 2 hours and 1 out of 2 was unable to determined time frame of assistance. 2 out of 5 residents were unable to answer due to cognitive skills. 1 out of 5 residents stated to be assisted to use the bathroom when needed. 5 out of 5 staff stated to have received training on incontinence care, 4 of the 5 staff stated residents with incontinence needs are changed every 2 hours and 1 of the 5 staff stated residents are change 3 times during the day and 3 times during the night. Documents reviewed revealed 2 out of 5 residents need assistance with incontinence care, facility does not maintain a log for incontinence care, and staff training regarding incontinence care was provided to staff within the year.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Regarding allegation: Staff are not assisting resident with transfers. It is alleged staff does not take R1 out of bed. Interviews with residents revealed 2 out of 5 residents stated to be assisted with getting out of bed/chair when needed. 2 out of 5 residents were unable to answer due to cognitive skills, and 1 out of 5 residents stated to not be assisted getting out of bed.

(CONTINUED LIC 9099C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211102102416

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: 06/02/2022

NARRATIVE

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Interviews with staff revealed 5 out of 5 staff stated to assist the residents with transfer from bed to chair, provided by 2 caregivers, and to have received training for proper transfer care including use of hoyer lifter. 2 out of the 5 staff stated R1 chooses to return to bed after being assisted out of bed most of the time. Documents reviewed revealed R1 has noted motor impairment on physician's report. LPA reviewed Lift Program Policy and Guide for staff training within the last year.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted with Paula Mera Caregiver and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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