198200233-12-28-2020-11-AS-MCAA-BXGSPM-20210121130318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198200233
Report Date: 12/23/2020
Date Signed: 12/28/2020 03:34:07 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

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:	12/23/2020
		UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Joy Membrebe, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Due to neglect and lack of care and supervision, resident sustained pressure injury while in care

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.

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: 12/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

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: 12/23/2020

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:

(Due to neglect and lack of care and supervision, resident sustained pressure injury while in care)

Based on review of medical documentation from Vitas Hospice Care, it was documented that R1 had a stage 3 coccyx injury and a stage 3 right foot injury on 9/19/2019. R1 was not ambulatory and needed help with ADLs but was not bedridden. There is nothing in hospice notes that states that R1 needed to be repositioned every so often to prevent pressure injuries. It was first noted by Vitas Hospice Care that there was a blister on R1’s right foot on 8/26/19. Also, the coccyx wound was initially found on 9/18/19 and treatment was initiated that same day by Nurse Castro of Vitas Hospice. R1 was discharged from Charnock East the next day, on September 19, 2019.

Based on the information obtained, per interviews, review, and consultation with the Department’s legal branch, there was insufficient evidence that Charnock East acted negligently. Vitas Hospice agency believes that Charnock East complied with and maintained the care plan for R1.

According to the facility Administrator Joy Membrebe and Vitas Hospice, the Administrator was given basic debriefing and updates after hospice care visits. The debriefing usually included instruction to clean R1’s wound sites and keep R1’s leg elevated. Throughout the hospice care process, it was noted by Vitas Hospice that the Administrator had a good understanding of the hospice plan and treatment for R1. Ms. Membrebe cleaned R1’s foot wound and applied triple antibiotic ointment. Ms. Membrebe also reinforced treatment per doctor’s orders and assisted R1 with elevating lower extremity. R1’s foot wound dressing was changed every day. Vitas Hospice providers did not have any concerns about case issues at Charnock East.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 12/23/2020

NARRATIVE

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According to staff members at Charnock East, R1 would be changed in the morning before he got out of the bed and before and after lunch and dinner. R1 would also be changed as needed and taken to the bathroom 6-7 times per day. Based on interviews, residents generally felt that staff take good care of them.

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, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) 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: 12/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

LIC9099 (FAS) - (06/04)

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