197802563-1-19-2024-28-AS-FFIS-D26N5K-20240205090938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802563
Report Date: 01/19/2024
Date Signed: 01/19/2024 04:59:30 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
01/18/2024 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20240118114620

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: 14	DATE:	01/19/2024
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Alberto Galvan, administrator assistant		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained an injury due to staff neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an initial unannounced investigation regarding the above-mentioned allegations at the facility today. LPA explained the purpose of today's visit to Alberto Galvan, administrator assistant, who assisted with this visit.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #4 (S4); interviews of resident from resident#1 (R1) through resident#4 (R4); reviewed resident#1’s record reviews, and a facility tour. LPA obtained copies of the staff /resident rosters and R1’s resident records with relevant information.

In regard of the allegation resident sustained an injury due to staff neglect, it was alleged that a resident had a bruise on resident’s right eye. The investigation revealed the following: Per resident interviews, all residents from R1 to R4 could not corroborate the allegation. (-continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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-20240118114620

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: 01/19/2024

NARRATIVE

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Residents’ interviews revealed that staff provided appropriate care to residents. Per staff interviews, all four (4) staff, including the administrator, denied the allegation. File review revealed resident#1 (R1) got agitated in R1's room trying to get up. R1 fell on the floor as a result. As soon as the administrator aware of the incident, administrator checked on R1 and observed R1’s bruise on R1’s right eye. Administrator took immediate action to notify R1’s responsible party and R1’s physician. Administrator conducted an internal investigation on this incident. It was a single incident which resident fell and got bruise on the resident's eye. Ice pack immediately applied to the resident. Per R1’s physician visit, it stated R1’s bruise was all gone and no medical concern after the fall. An in-service training on resident’s fall risk was provided to staff. Per LPA's observation, R1 was doing fine and bruise was all gone. Therefore, the resident was injured due to staff neglect was not observed.

Although the allegation may have happened or is valid, there’s not preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Alberto Galvan, administrator assistant. Findings were discussed. A copy this report was provided at the time of visit.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC9099 (FAS) - (06/04)

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