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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198200516
Report Date: 10/25/2024
Date Signed: 10/25/2024 02:42:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2024 and conducted by Evaluator Elvira Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240503135003
FACILITY NAME:SOCIAL VOCATIONAL SERVICES LOMITA RESIDENTIAL HOMEFACILITY NUMBER:
198200516
ADMINISTRATOR:SHARON HOPPERFACILITY TYPE:
735
ADDRESS:24512 WOODWARD AVENUETELEPHONE:
(310) 517-0960
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 2DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Pleshette Jackson-RSS1TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Client sustained fractures while in care due to staff neglect.
Lack of supervision resulting in resident sustaining multiple falls .
Facility staff did not administer medication as prescribed.
INVESTIGATION FINDINGS:
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On 10/25/24, the department conducted a subsequent complaint visit to this facility to conclude the investigation and deliver findings. The department met Residential Support Specialist (RSS) 1, Pleshette Jackson, and explained the purpose of this visit. Administrator, Sharon Hopper, later joined the department for the visit.

Investigation consisted of the following: On 05/06/24, the department gathered the following documents: staff roster, resident roster, staff schedule for the dates of 04/18/24 – 04/23/24, and reviewed client files (C1-C3). Collected copies of Unusual Incident Reports, Harbor Regional Center Telehealth Nursing Assessment, Physician’s Report, Physician Orders, Medication Administration Destruction Record, Medication Administration Records (MARs), R.O. A. D. S. Community Care Clinic, records from Torrance Memorial Medical Center, Social Vocational Services Lomita Individual Quarterly Report for reporting period 09/23-11/23, and Daily Body Check Logs pertaining to client #1 (C1).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 7
Control Number 11-AS-20240503135003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SOCIAL VOCATIONAL SERVICES LOMITA RESIDENTIAL HOME
FACILITY NUMBER: 198200516
VISIT DATE: 10/25/2024
NARRATIVE
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Harbor Regional Center Individual Person-Centered Plan (IPP) dated: 09/05/24 for C1 was provided to the department on 10/25/24. A health and safety check and a tour of the entire facility was conducted with Administrator Sharon Hopper. Interviews were conducted with staff #1-#5 (S1-S5), witness #1-#2 (W1-W2) and attempted to interview clients #1-#3 (C1-C3). The department was unable to interview staff #6 (S6) as they are no longer employed by the facility and was unable to reach them. Additionally, the department requested for a fall risk plan for C1, but according to Administrator Sharon Hopper, they do not have one available.

INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Client sustained fractures while in care due to staff neglect. It is being alleged that a client sustained fractures after a fall due to neglect. The department conducted a review of records and found that it was noted on the facility’s Service Notes for Current Residents that on 04/18/24 C1 was attempting to open the fridge and staff redirected C1 to go to the living room. C1 then took a step from the sunken (one-step) kitchen to the hallway and fell on their buttocks, resulting in a small bruise. Staff then reported this incident to Administrator Sharon Hopper, and she instructed staff to administer first aid. A review of the MAR for April 2024 for C1 revealed Ibuprofen (800mg) was administered to C1 on 04/18/24 and 04/19/24. An Unusual Incident Report (dated: 04/24/24) was submitted to the department reporting that on 04/23/24 C1 was taken to the hospital after staff noticed bruising and swelling on C1s lower back. According to records from Torrance Memorial Medical Center, C1 was admitted to the hospital on 04/23/24 for acute rib fractures and traumatic hemothorax that required an immediate chest tube insertion. An Unusual Incident Report (dated: 04/30/24) was submitted to the department reporting on 04/30/24 C1 was discharged rom the hospital with home health for physical therapy. A review of the Residential Health Care Plan (dated: 08/20/23) states that C1 is a fall risk under the section Problems, Needs, Concerns, and the facility’s approach to this concern is by monitoring C1 daily, making sure that C1 always wears appropriate footwear (socks, with grips on bottom, shoes that fit comfortably and not loose). A review of the Harbor Regional Center’s IPP (dated: 09/05/24) for C1 states that staff must be close by C1. If staff turn their back, C1 will do a sudden movement and that will cause C1 to fall.

During two unannounced visits, the department observed minimal light inside the facility. No lights were turned on and only natural light from the windows illuminated the home.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20240503135003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SOCIAL VOCATIONAL SERVICES LOMITA RESIDENTIAL HOME
FACILITY NUMBER: 198200516
VISIT DATE: 10/25/2024
NARRATIVE
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The department interviewed S1-S5 and revealed that 5 out of 5 staff interviewed were aware that C1 is a fall risk, and they were instructed to track C1 while C1 was mobile to minimize falls and/or injuries. 4 out of 5 staff interviewed confirmed C1 had a witnessed fall on 04/18/24. S5 stated they were at the facility on 04/18/24 with C1 when they fell. S5 stated that C1 went into the refrigerator and S5 redirected C1 towards the living room. S5 stated C1 became upset and as C1 stepped onto the hallway, they lost balance and fell back. S5 stated they heard C1 make a grunting sound as if they were in pain. S1 assisted S5 to help C1 up and S2 then took a photograph of C1’s back which was observed to be red. 3 out of 5 staff interviewed stated that this incident was immediately reported to Hopper, and that that Hopper directed them to apply first aid (ice pack, and Ibuprofen for pain), and monitor C1. An interview with S4 revealed they had no explanation as to why there was a delay in medical attention after C1’s fall on 04/18/24.

The department attempted to interview C1-C3 but C1-C2 non-verbal and C3 was not available.

Based on the department’s observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.



Continued on LIC 9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20240503135003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SOCIAL VOCATIONAL SERVICES LOMITA RESIDENTIAL HOME
FACILITY NUMBER: 198200516
VISIT DATE: 10/25/2024
NARRATIVE
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Allegation: Lack of supervision resulting in resident sustaining multiple falls. It is being alleged that a resident was admitted to the hospital for multiple falls. A review of records revealed that an Unusual Incident/Injury Report (dated 08/15/22) was submitted to the department reporting that on 08/12/22, C1 was taken to the hospital due to a fall resulting in an abrasion on his right knee, blunt head injury, dental trauma, and laceration to right eyebrow. C1 was discharged that same day. An Unusual Incident/Injury Report (dated 05/21/23) was submitted to the department reporting that on 05/20/23, C1 had a misstep and fell on the floor resulting in a scratch on his head above the left eyebrow. An Unusual Incident/Injury Report (dated 01/24/24) was submitted to the department reporting that on 01/23/24, staff heard a thump sound that came from the front bedroom hallway and found C1 lying on the hallway floor on their left side. 911 was called and C1 was taken to the hospital due to the fall resulting in head injury (laceration of the head) with five dissolvable stitches for the cut. An Unusual Incident/Injury Report (dated 04/24/24) was submitted to the department and reported that on 04/23/24, C1 was taken to the hospital due to a fall on 04/18/24 resulting in C1 being admitted to the hospital on 04/23/24 for acute rib fractures and traumatic hemothorax that required an immediate chest tube insertion. A review of the facility’s Individual Personal Program Plan Summary (dated: 08/21/23) revealed that C1 is a fall risk and will fall by standing up too fast and/or walking too quickly. A review of the Residential Health Care Plan (dated: 08/20/23) states that C1 is fall risk under the section Problems, Needs, Concerns, and the facility approach to this concern is by monitoring C1 daily, making sure that C1 always wears appropriate footwear (socks with grips on bottom, shoes that fit comfortably and not loose).

The department interviewed S1-S5 and revealed that 5 out of 5 staff interviewed were aware that C1 is a fall risk, and they were instructed to track C1 while they were mobile to minimize falls and/or injuries.

The department attempted to interview C1-C3 but C1-C2 non-verbal and C3 was not available.

Based on the department’s observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.


Continued on LIC 9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20240503135003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SOCIAL VOCATIONAL SERVICES LOMITA RESIDENTIAL HOME
FACILITY NUMBER: 198200516
VISIT DATE: 10/25/2024
NARRATIVE
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Allegation: Facility staff did not administer medication as prescribed. It is alleged that a resident was admitted to the hospital for ingesting another resident’s medications. A review of records revealed that an Unusual Incident/Injury Report (dated: 03 /08/24) was submitted to the department reporting that on 03/08/24 at 08:15 AM, S2 prepared to administer C2 medication. S2 placed medications for C2 into a cup and then handed them to S6 to check and verify the correct medications were in the cup for C2. S6 then proceeded to administer the medications prepared for C2 to C1. Administrator Sharon Hopper was notified, and she advised staff to monitor C1 for any side effects. When Hopper arrived at the home, C1 was then transported to the hospital.

An interview conducted with S1 revealed that they were aware that S6 did not administer the medications as prescribed. S1 stated that S6 gave C1 the medications prepared for C2 in error.

An interview conducted with S2 revealed that they were present on 03/08/24 when S6 gave C2s medication to C1 in error. S2 stated they prepared the medication for dispensation then S6 verified the medication was correct and verbally confirmed it was for C2. S2 stated that S6 proceeded to give C1 the medication dispensed for C2. When S2 and S6 realized that C1 had ingested C2’s medication, they immediately notified Administrator, Sharon Hopper.

The department attempted to interview C1-C3 but C1-C2 non-verbal and C3 was not available.

Based on the department’s observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.


An exit interview was conducted with Administrator Sharon Hopper, and a copy of the report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20240503135003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SOCIAL VOCATIONAL SERVICES LOMITA RESIDENTIAL HOME
FACILITY NUMBER: 198200516
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2024
Section Cited
CCR
80075(a)
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80075(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This was not met as evidence by:
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Licensee shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 80075(a). Written POC must be submitted to CCL by the POC due date.
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Based on record review, observation, and interviews conducted. C1 suffered a severe fall on 0104/18/24 that required immediate medical attention. Staff administered first aid for pain. C1 was admitted to the hospital five days after the witnessed fall on 04/23/24 for acute rib fractures, and traumatic hemothorax which required an immediate chest tube insertion.
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Type A
10/26/2024
Section Cited
CCR
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85075.4 (a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning. (b) The licensee shall provide assistance when observation reveals needs which might require a change in the existing level of service, or possible discharge or transfer to another type of facility. This was not met as evidence by:
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Licensee shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 85075.4(a)(b). Written POC must be submitted to CCL by the POC due date.
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Based on record review, observation, and interviews conducted. C1 has suffered multiple falls on 08/12/22, 5/20/23, 01/23/24, and on 04/18/24 due to lack of supervision.
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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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20240503135003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SOCIAL VOCATIONAL SERVICES LOMITA RESIDENTIAL HOME
FACILITY NUMBER: 198200516
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
80075(b)
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80075(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This was not me as evidence by:
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Licensee shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 80075(b). Written POC must be submitted to CCL by the POC due date.
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Based on record review, observation, and interviews conducted. On 03/08/24 S6 gave C1, another client's (C2) medication in error.
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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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7