198200233-7-28-2020-11-AS-MCAA-BXGSPN-20210121130319

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198200233
Report Date: 07/28/2020
Date Signed: 07/28/2020 04:59:55 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: 5	DATE:	07/28/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Joy Membrebe, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Unqualified staff were caring for resident's wound (blister)
Facility failed to properly manage resident's incontinence

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.

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).

Unsubstantiated

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: 07/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020

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: 07/28/2020

NARRATIVE

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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:

(Unqualified staff were caring for resident's wound (blister))

Based on observation, record review, and interview, the Administrator was trained by Vitas Hospice Care on how to care for and clean R1’s wound. The Administrator changed the dressing on R1’s wound and would show Vitas Hospice the wound. All other staff did not clean or care for R1’s wound.

The investigation revealed the following for allegation:

(Facility failed to properly manage resident's incontinence)

Based on interviews, the facility maintained a changing schedule for the residents. The facility also took R1 to the restroom 6-7 times per day or as needed.

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), and the interviews that were conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

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: 07/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020

LIC9099 (FAS) - (06/04)

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