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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198201496
Report Date: 04/09/2021
Date Signed: 04/09/2021 04:09:54 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2019 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20191203083001
FACILITY NAME:BEVERLY HILLS GARDENS CARE CENTERFACILITY NUMBER:
198201496
ADMINISTRATOR:JOHN STIENFIELDFACILITY TYPE:
740
ADDRESS:1470 S. ROBERTSON BLVDTELEPHONE:
(310) 273-3668
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:0CENSUS: 93DATE:
04/09/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:John StienfieldTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff handles resident in a rough manner.
Facility staff mismanaged residents' medication.
Financial Abuse
Facility staff failed to provide adequate food service.
Facility staff are not properly trained.
Facility staff failed to meet residents' needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez initiated a telephonic subsequent complaint investigation to deliver investigation 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 Licensee John Stienfield.

Investigation consisted of the following: During the initial visit conducted on 12/11/19, LPA Gonzalez obtained a copy of Staff and Resident Rosters, and facility menu plan for 5 weeks. LPA interviewed Administrator John Stienfield, and Administrator/Controller Bella Naygas. LPA conducted a tour of facility kitchen, dining room, and Medication Room. LPA additionally interviewed Residents 1-7 (R1-7). On 4/9/21, LPA Gonzalez called Beverly Hills Terrace, License #198603319 and spoke to Administrator Clifford Johnson and requested and received the following documents: Medication Administration Records (MARs), copies of Records of Client's/ Resident's Safeguarded Cash Resources (LIC405) and copies of staff training certificates regarding medication training.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
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 28-AS-20191203083001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BEVERLY HILLS GARDENS CARE CENTER
FACILITY NUMBER: 198201496
VISIT DATE: 04/09/2021
NARRATIVE
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The investigation revealed the following: In regard to allegations, Facility staff handles resident in a rough manner, it is alleged that staff at the facility show aggressive behavior towards facility residents, such as slamming residents room doors and if residents ask staff a question they are told that staff do not have time. It is also alleged that staff shake residents when they scream. Interview conducted with Administrator Bella Naygas revealed that residents are treated with dignity and respect. Administrator Naygas denied that she has ever screamed or handled any resident in a manner that might be considered rough or ever slammed resident room doors. Administrator Naygas also denied ever screaming at any resident. Interview with Administrator John Stienfield revealed that he is not aware of any staff at facility mistreating, physically abusing or screaming at any facility resident. Mr. Stienfield stated that facility staff are properly trained on resident's personal rights, he has a very good relationships with facility residents and he has not received any complaints from residents regarding any staff acting inappropriately towards residents. Mr. Steinfield stated that he ensures that facility residents are treated with dignity and respect at all times and residents know that he has an open door policy. Interviews with R1-7 revealed that they are satisfied with their interactions with facility staff, staff do not scream at residents and staff do not handle residents in a rough manner. R1-7 stated that staff are respectful, helpful and tend to their needs and stated that they do not have any concerns regarding the facility staff. Based on interviews conducted with facility staff and facility residents, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility staff mismanaged residents' medication, it is alleged that facility staff are not properly trained on medication as staff mismanage resident's medications for a long time, resident's medication would be missing and sometimes staff administer the wrong medication due to staff being confused and lack of knowledge. Interview with Administrator Stienfield and Naygas revealed that staff do not mismanage resident's medications. Administrator Naygas stated that staff who give medications to residents are properly trained and have participated in-service trainings for medication administration and all other required training. Administrator Stienfield stated that he is not aware of any concerns regarding resident's medications being mismanaged and stated that every time residents receive their medications, staff ensure that it is properly documented on resident's Medication Administration Records (MARs). Mr. Stienfield and Mrs. Naygas both stated that medications are always stored in the locked medication room and residents do not have access to that room. The only people that have access to the medication room are the administrators and appropriate staff. Interviews with R1-7 revealed that they receive their medications timely and as needed and stated that they did not have any concerns regarding staff at facility mismanaging their medications. LPA Gonzalez conducted a tour of the facility medication room and
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20191203083001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BEVERLY HILLS GARDENS CARE CENTER
FACILITY NUMBER: 198201496
VISIT DATE: 04/09/2021
NARRATIVE
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observed that the room was locked, proper record keeping of medication administration is on file and medication appeared to be properly stored in bubble packs separated by resident's names. LPA also requested and reviewed copies of MARs for R1-7 and did not observe anything that might indicate mismanaging of resident's medications. Based on interviews conducted with facility staff, facility residents, LPAs observations and review of documents there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Financial Abuse, it is alleged that residents are financially abused by facility staff and facility staff use residents funds to order items such as diapers, wheelchairs, and bathroom chairs but do not give those items to the residents but sell the items to other facilities. Interview with Administrator Stienfield and Naygas revealed that most residents that reside at the facility are SSI recipients and the majority of the residents chose to collect all their money in full as soon as it is available and proper record is kept for all residents funds. Administrator Stienfield and Naygas both denied using residents money to purchase items such as diapers, wheelchairs or bathroom chairs and stated that such items if needed for any resident are ordered through the resident's medical insurance upon insurance approval. Interviews with R1-7 revealed that they have no concerns regarding getting their monthly Personal and Incidental (P&I) money and they are always able to get all their money or partial money if they chose on a weekly basis. R1-7 stated that P&I money is handed out to residents weekly on Tuesdays. LPA reviewed Records of Client's/ Resident's Safeguarded Cash Resources (LIC405) logs for R1-7 and observed dates, amounts and balances for resident's money and did not observe that any amounts on the logs were inaccurate. Based on interviews conducted with facility staff and R1-7, LPA review of documents collected there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility staff failed to provide adequate food service, it is alleged that the food served at the facility is not good quality and the facility does not provide residents with a variety of food and resident's are consistently served only hash browns, sausage, chicken or eggs. Interview with Administrator Stienfield and Naygas revealed that the facility serves a variety of food and follows the facility 5 week menu plan which is rotated every 5 weeks. Administrator Stienfield stated that the facility does serve hash browns, sausage, chicken and eggs but those are not the only food that is served to residents. He stated that the facility serves a variety of meals which includes vegetables, fruits, meats, dairy and legumes. Administrator stated that residents are served 3 full meals and 2-3 snacks a day and there is always water and coffee available for residents throughout the day. Interviews with R1-7 revealed that the facility serves a variety of food and they
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20191203083001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BEVERLY HILLS GARDENS CARE CENTER
FACILITY NUMBER: 198201496
VISIT DATE: 04/09/2021
NARRATIVE
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are satisfied with the food service at the facility. R1-7 stated that they are served 3 meals and 3 snacks and also fruits and sandwiches if they are hungry between meals. R1-7 stated that they have no concerns regarding food service at the facility and they stated that the facility provides adequate food service and they are served a variety of foods. LPA reviewed facility 5 week menu plan and observed that the facility serves a variety of meals on a daily basis and the meals consist of a variety of vegetables, fruits and protein. Based on interviews conducted with facility staff and R1-7, LPA review of facility menus there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility staff are not properly trained, it is alleged that facility staff are not properly trained as it is alleged that the staff mismanage resident's medications. It is also alleged that staff open resident's mail without their permission and throw the resident's mail in the trash. Interviews conducted with facility administrator John Stienfield and Bella Naygas revealed that staff are properly trained. They also denied that staff open resident's mail. Mr. Stienfield and Mrs. Naygas both stated that residents come to the front office to collect their mail daily and resident's mail is never thrown in the trash by staff. They stated that resident's at times throw some of their mail in the trash after they read it. Mr. Stienfield stated that he constantly tells resident's that throwing their mail in the trash is not a good idea as they can throw something with their private information which can be used for identity theft. R1-7 stated that they have not had any issues or concerns regarding their mail and stated that their mail is kept at the front office. They stated that they just go to the front office and ask if they have mail and if they do mail is given to them. LPA requested and reviewed staff training certificates and observed that staff completed required training. LPA also observed resident's inquire about their mail at the front office. Based on interviews conducted with facility staff and R1-7, LPA review of documents collected and LPA observations there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility staff failed to meet residents' needs, it is alleged that facility staff scream at residents and shake residents and if a residents asks a staff anything staff tell residents that they don't have time. Interviews conducted with Administrator Stienfield and Naygas revealed that staff never scream at residents, staff do not shake residents and staff never ignore residents. Interviews conducted with R1-7 reveled that staff at the facility tend to their needs and that Administrator Stienfield constantly checks on the residents to see how they are doing. R1-7 stated that they are aware that the facility is going to be sold soon and are worried that the new management will be different and not care for them like Mr. Stienfield does.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20191203083001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BEVERLY HILLS GARDENS CARE CENTER
FACILITY NUMBER: 198201496
VISIT DATE: 04/09/2021
NARRATIVE
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Interviews with R1-7 revealed that they are satisfied with all services and treatment given to them and have no concerns. Based on interviews conducted with facility staff and R1-7, there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Due to measures implemented due to COVID-19, exit interview was conducted with Administrator Stienfield via telephone. A copy of the report for complaint investigation regarding closed facility License #198201496 was sent via email for signature and a hard copy was mailed to licensee to address on record for License #198201496. A hard copy with signature is on file.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5