198201933-6-12-2020-11-AS-EMAZ-BQTUHK-20200622153605

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201933
Report Date: 06/12/2020
Date Signed: 06/12/2020 04:15:15 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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2020 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200506150649

FACILITY NAME:	PALOS VERDES VILLA LLC		FACILITY NUMBER:	198201933
ADMINISTRATOR:	BIENSTOCK, SETH		FACILITY TYPE:	740
ADDRESS:	29661 S WESTERN AVE		TELEPHONE:	(310) 547-9941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	116	CENSUS: 85	DATE:	06/12/2020
		UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Seth Bienstock		TIME COMPLETED:	11:57 AM

ALLEGATION(S):

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Resident forced to relocate to another room.
Staff bully and undermined residents.
Resident inappropriately touching other residents.

INVESTIGATION FINDINGS:

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On 06/12/20 Licensing Program Analyst, LPA/Ernand Dabuet initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Seth Bienstock/Administrator and Linda Cardenas/Assistant Administrator.

The investigation consisted of the following: Interviews with staff and residents. A review of staff/resident roster, admissions agreement, pre-placement appraisal, physician’s report, needs service plan, facility brochure, and other pertinent documents pertaining to the allegations. A tour of the plant facility.

Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020

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-20200506150649

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
MONTERY PARK, CA 91754

FACILITY NAME: PALOS VERDES VILLA LLC	FACILITY NUMBER: 198201933
	VISIT DATE: 06/12/2020

NARRATIVE

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Allegation: Resident forced to relocate to another room
Staff bully and undermined resident

The Department conducted interviews with staff (S1 - S6) and residents (R2-R8) from this facility. A review of (R1)'s medical records, medications, resident’s appraisal, admission’s agreement, and other pertinent records including R1's statement were completed and found there is no evidence to support the allegations mentioned above. There is no evidence of R1's personal rights were violated that resulted in the "Resident forced to relocate to another room" or "Staff bully and undermined resident". The residents who have shared a room with (R1) in room #62 were interviewed and all indicated no evidence of staff bullied or pressured residents to relocate to other rooms. Investigation revealed (R1) has been living at this facility for seven years and has gone through several roommates due to incompatibility with roommates. (R1) was interviewed and indicated (R1) did not mind moving to another room as long as it was a resident that (R1) got along with. (R1) states the administrator provided her the option on a trial basis to move into room #45 prior to being permanently placed. (R1) states the administrator found her a former roommate who she was compatible with, a large room, a corner room, one shared wall, a balcony, and no additional increase in rent. (R1) reports her personal rights were not violated and regrets filing the complaint. (R1) had indicated it is a misunderstanding. Residents were interviewed and report that the staff treats them appropriately. Interviews with staff and residents revealed, residents are treated with dignity and respect.

Allegation: Resident inappropriately touching other residents.

It is alleged that (R4) touches men and women inappropriately. The administrator states that (R1) had addressed the matter and that management had spoken with (R4). This issue was not elevated to CCLD as management conducted their own inquiry. It revealed after speaking with residents involved that the allegation did not involve inappropriate behavior. (R4) denies having inappropriate contact with (R1). (R4) states that (R4)’s actions are misconstrued by (R1). (R4) reports no further in-person contact with (R1). The staff and residents interviewed confirmed that no improper behavior has been exhibited by (R4). (R1) verified that (R4) did not engage in inappropriate behavior. Based on the information obtained, the Department did not find evidence to support any inappropriate behavior.

Evaluation Report continues on LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200506150649

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
MONTERY PARK, CA 91754

FACILITY NAME: PALOS VERDES VILLA LLC	FACILITY NUMBER: 198201933
	VISIT DATE: 06/12/2020

NARRATIVE

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Based on information gathered, LPA did not find sufficient evidence to support allegations, “Resident forced to relocate to another room,” “Staff bully and undermined resident” and “Resident inappropriately touching other residents.”

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.

A telephonic exit interview was conducted with Seth Bienstock, and a hard copy was provided via email for signature

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020

LIC9099 (FAS) - (06/04)

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