198200233-12-28-2020-11-AS-MCAA-BXGSPL-20210121130317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198200233
Report Date: 12/24/2020
Date Signed: 12/28/2020 03:29:21 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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2019 and conducted by Evaluator Erik Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20191016134227

FACILITY NAME:	CHARNOCK EAST		FACILITY NUMBER:	198200233
ADMINISTRATOR:	JOY MEMBREBE		FACILITY TYPE:	740
ADDRESS:	11365 CHARNOCK RD		TELEPHONE:	(310) 391-2423
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	6	CENSUS: 3	DATE:	12/24/2020
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Joy Membrebe, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident was transported in an unsafe manner

INVESTIGATION FINDINGS:

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On this date, Licensing Program Analyst (LPA) Erik Brown conducted an unannounced complaint tele-visit to deliver findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Joy Membrebe, the facility Administrator.

During the initial visit on 10/18/2019, LPA discussed the allegation with Administrator Joy Membrebe. LPA toured the facility and collected pertinent documents related to the investigation.

During the visit on 11/4/2019, LPA discussed the allegation with Administrator and Licensee Sam Maghazei. LPA toured the facility and collected further documentation related to the investigation. LPA asked S1 and S2 to demonstrate how a resident who is wheelchair bound would be safely transported in the facility's van. S2 demonstrated how the facility staff secures wheelchairs in the facility's van. LPA took pictures of the wheelchair inside of the van.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2020

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 11-AS-20191016134227

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: CHARNOCK EAST	FACILITY NUMBER: 198200233
	VISIT DATE: 12/24/2020

NARRATIVE

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During the visit on 12/10/2019, LPA toured the facility and collected further information and documentation related to the investigation. LPA interviewed staff#1 (S1), staff #3 (S3), and staff #4 (S4).

During the visit on 12/20/2019, LPA discussed the allegation with Administrator. LPA toured the facility and interviewed clients #2-6.

The investigation revealed the following for allegation:

(Resident was transported in an unsafe manner)

On 11/4/2019, LPA observed the method that the Licensee used to securely transport R1 while R1 sat in his wheelchair in the facility vehicle. The licensee wrapped multiple seatbelts around the wheelchair in several directions in an effort to secure it to the floor of the vehicle that is used to transport the facility’s residents. LPA took pictures of the scene after the seatbelts were fastened around the wheelchair.

Based on LPA Brown’s observations, the records that were reviewed (Vitas Hospice Care documentation, Assisted Hospice Care documentation, R1’s admission agreement, physician’s report, appraisal, individual plan of care, UCLA Medical documentation, photographs), and the interviews that were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be substantiated.

A telephonic exit interview was conducted with the facility Administrator Joy Membrebe and a hard copy of this report was provided via email for signature.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2020

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20191016134227

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: CHARNOCK EAST	FACILITY NUMBER: 198200233
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/24/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/07/2021 Section Cited CCR 87312	1 2 3 4 5 6 7	Only drivers licensed for the type of vehicle operated shall be permitted to transport residents. The rated seating capacity of the vehicles shall not be exceeded. Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition. This requirement was not met as evidenced by: Based on observation, and photo review	1 2 3 4 5 6 7	For future transportation of wheelchair bound residents, the Administrator is to utilize a certified transportation company that can safely transport residents who are bound to their wheelchairs. Otherwise, if the facility is to transport a resident that is wheelchair bound, the facility must remove the resident from their wheelchair and assist with placing the
	8 9 10 11 12 13 14	,the facility’s transportation vehicle was not safe to transport a wheelchair bound resident, which presented a potential health and safety risk to resident in care.	8 9 10 11 12 13 14	resident on the seat of the car and safely secure the resident with the car’s seatbelt. Administrator will provide LPA with a specific plan regarding transporting wheelchair bound residents in care by the POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2020

LIC9099 (FAS) - (06/04)

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