197802917-9-21-2022-28-AS-LHIS-CK3TBS-20221010143534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802917
Report Date: 09/21/2022
Date Signed: 09/21/2022 01:02:53 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
10/12/2020 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201012122450

FACILITY NAME:	RED ROSES VILLA		FACILITY NUMBER:	197802917
ADMINISTRATOR:	BRIAN BUENVIAJE		FACILITY TYPE:	740
ADDRESS:	13805 E. CREWE STREET		TELEPHONE:	(562) 941-3813
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY:	18	CENSUS: 11	DATE:	09/21/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Gloria Gibson		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility failed to seek timely medical treatment.
Facility is not assisting resident with ADLs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Assistant Administrator, Gloria Gibson who assisted with today's visit.

Regarding the allegation that facility failed to seek timely medical treatment for resident #1 and facility is not assisting resident #1 with ADLs. The investigation was conducted by the department and consisted of
interview(s) with Administrator, facility staff, hospital medical personnel, and Resident #1. Review of Resident #1's file including medical records was also conducted.

The investigation revealed the following: Administrator and staff interviewed denied that resident #1 fell at the facility. Facility staff indicated that they send resident(s) to the hospital to be assessed if they fall. Facility staff sent Resident #1 to be assessed at the hospital on 10/12/20, when it was observed that resident #1 had swelling on her left ankle. Resident #1 was determined to have a left ankle fracture when admitted to the hospital. Medical personnel interviewed stated that it is not clear when Resident #1 sustained the fracture.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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-20201012122450

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: RED ROSES VILLA	FACILITY NUMBER: 197802917
	VISIT DATE: 09/21/2022

NARRATIVE

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Facility staff interviewed, stated that they assist resident(s) with their ADL's. Staff stated that they attempted to assist resident #1 with changing her clothes on 10/12/20, prior to sending her to the hospital. Staff stated that resident #1 was in pain and refused assistance and did not allow staff to change her clothing.

Attempts were made to interview Resident #1. However, resident #1 is nonverbal and was unable to provide any information regarding the allegations.

Based on LPA's observations and interviews, investigation revealed: 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.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview conducted and copy of report was provided to Assistant Administrator, Gloria Gibson.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC9099 (FAS) - (06/04)

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