198200416-12-6-2021-11-AS-MCAA-CB8NB8-20220201091840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198200416
Report Date: 12/03/2021
Date Signed: 12/06/2021 08:14:29 AM

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
11/29/2021 and conducted by Evaluator Susan Campos

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211129122142

FACILITY NAME:	THEL'S BOARD AND CARE		FACILITY NUMBER:	198200416
ADMINISTRATOR:	WILLIAMS, THELMA E.		FACILITY TYPE:	740
ADDRESS:	969 W. VERNON AVE		TELEPHONE:	(323) 231-4544
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90037
CAPACITY:	14	CENSUS: 7	DATE:	12/03/2021
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Thelma Williams		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff is not screening for COVID.
Staff is not allowing residents to depart from the facility.
Staff is not allowing residents to meet with visitors in private.

INVESTIGATION FINDINGS:

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On 12/3/2021 at 8:25 a.m., Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegations listed above. LPA was allowed entry into the facility by Administrator Thelma Williams. LPA explained to Ms. Williams the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (2) staff member and (3) residents on 12/3/21. In addition, on 12/3/21, LPA and Ms. Williams conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. LPA also reviewed the following documents provided by Thel’s Board and Care administrator Thelma Williams: LIC 500-staff roster, client roster, staff schedule, Incident Reports from November 2021 to present, Internal staff incident reports from November 2021 to present, House Rules, and Facility Visitation Procedures.

Report continued on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 11-AS-20211129122142

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: THEL'S BOARD AND CARE	FACILITY NUMBER: 198200416
	VISIT DATE: 12/03/2021

NARRATIVE

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Allegation: Staff is not screening for COVID.

The investigation revealed, per LPA interviews, with (2) staff members, and (3) residents from the Thel’s Board and Care facility, and also review of facility documents, that staff at the Thel’s Board and Care facility do not screen visitors for COVID. S1 informed LPA that the facility does not have visitors, and that only medical staff enter the facility to meet the resident, and that is why there is no COVID screening process in the facility. S1 further stated, that did not know that everyone entering the facility needed to be screened.

On 12/3/21, at 8:25 am, LPA Campos did not receive COVID screening when entering the facility, and did not observe a COVID screening station. LPA Campos requested Administrator Williams to conduct a COVID screening before LPA entered the facility.

Based on information gathered, LPA did find sufficient evidence to support allegation "Staff is not screening for COVID.”

Allegation: Staff is not allowing residents to depart from the facility.
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The investigation revealed, per LPA interviews, with (2) staff member, and (3) residents from the Thel’s Board and Care facility, and also review of facility documents, that the staff at the Thel’s Board and Care facility are not allowing residents to depart from the facility. S1 informed LPA, that does not allow the facility residents to leave the facility, because of the COVID pandemic, and is fearful of the residents bringing COVID to the facility if they are allowed to go out. S1 further stated, that the residents do leave the facility for doctor appointments, and staff accompanied store trips. In addition, LPA interviewed (3) residents, and 3 of 3 residents interviewed, informed LPA, that they are not allowed to leave the facility, because of the COVID pandemic.

On 12/3/21, at 8:45am LPA was informed by S1, that S1 does not allow residents to leave the facility, because of COVID pandemic.

On 12/3/21, at 9:00am-9:30am, LPA was informed by 3 of 3 residents interviewed that they are not allowed to leave the facility, because of the COVID pandemic.

Report continued on LIC 9099C

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20211129122142

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: THEL'S BOARD AND CARE	FACILITY NUMBER: 198200416
	VISIT DATE: 12/03/2021

NARRATIVE

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Based on information gathered, LPA did find sufficient evidence to support allegation "Staff is not allowing residents to depart from the facility ”

Allegation: Staff is not allowing residents to meet with visitors in private.
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The investigation revealed, per LPA interviews, with (2) staff members, and (3) residents from the Thel’s Board and Care facility, and also review of facility documents, that staff at the Thel’s Board and Care facility do not allow residents to meet with visitors in private. S1 informed the LPA, that on 8/13/21, S1 was standing on the second floor hallway, outside the residents rooms, while Ombudsman, was conducting resident room interviews. Also, S1 stated that, did not comply with Ombudsman request, that S1 leave in order to conduct private resident interviews. Also, S2 informed LPA, that on 11/5/21, S2 did not comply with Ombudsman's request to conduct private interviews, in resident rooms, because only staff and residents are allowed on the second floor, and S2 stated that did not have the authority to allow Ombudsman on the second floor. S2 further stated, that S2 brought all the residents, from the second floor to the first floor, so that the residents may be interviewed by the Ombudsman on the first floor.

On 12/3/21, at 10:00 am, LPA was informed by S1, that on 8/13/21, did not allow Ombudsman to have private conversation with residents in their room as requested, and S2 informed LPA that on 11/5/21, S2 did not comply with Ombudsman's request to interview residents in their room on the second floor.

Based on information gathered, LPA did find sufficient evidence to support allegation " Staff is not allowing residents to meet with visitors in private ”

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. A exit interview was conducted with Thelma Williams, Administrator and a hard copy of a LIC 9099 and LIC 9099D was provided.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20211129122142

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: THEL'S BOARD AND CARE	FACILITY NUMBER: 198200416
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/07/2021 Section Cited HSC 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2)Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:…(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide per fax to LPA a COVID visitor screening procedures, and also a staff Sign-In sheet for staff training on the COVID visitor screening procedures. POC Due Date is 12/7/21 LPA Fax Number (323)981-1781
	8 9 10 11 12 13 14	Based on interviews, and record review, the licensee failed to ensure the safety of residents, by not providing a COVID screening for facility visitors. On 12/3/21, at 8:25am, LPA Campos was not provided COVID screening upon entering the facility, and LPA did not observe a COVID screening area which posed a potential health risk to residents in care.	8 9 10 11 12 13 14
Type B 12/08/2021 Section Cited HSC 87468.1(a)(6)	1 2 3 4 5 6 7	87468.1(a)(6)Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:…(6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide LPA per fax with a sign-in sheet from staff and residents, that have been informed by Administrator, Thelma Williams, that residents may leave and return to the facility. POC Due Date is 12/8/21 LPA Fax Number (323)981-1781
	8 9 10 11 12 13 14	Based on interviews, and record review, the licensee failed to allow residents to depart the facility. On 12/3/21, at 8:45 am, LPA Campos was informed by S1 that does not allow residents to leave the facility because of COVID pandemic, which posed a potential health risk to residents in care.	8 9 10 11 12 13 14

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: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20211129122142

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: THEL'S BOARD AND CARE	FACILITY NUMBER: 198200416
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/08/2021 Section Cited HSC 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1(a)(11) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:…(11)To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide LPA per fax, procedures for residents private conversations with Ombudsman, and other resident visitors, and also a sign in sheets informing staff and residents of their right to have visitors. POC Due Date is 12/8/21 LPA Fax Number (323)981-1781
	8 9 10 11 12 13 14	Based on interviews, and record review, on 12/3/21, at 10am, S1 and S2 informed the LPA that they did not comply with Ombudsman's request, on 8/13/21, and 11/5/21 for Ombudsman to conduct private resident interviews in resident's room, which posed a potential health risk to residents in care.	8 9 10 11 12 13 14
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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: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

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