198201933-11-12-2020-11-AS-AJKK-BVN2FU-20201123162203

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201933
Report Date: 11/12/2020
Date Signed: 11/12/2020 04:40:22 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
06/24/2020 and conducted by Evaluator Lourdes Montoya

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200624101208

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: 90	DATE:	11/12/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Seth Bienstock		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff harassing resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced complaint visit to deliver findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically/FaceTime with Administrator Seth Bienstock.

Investigation consisted of the following: Interviews with staff and residents. A review of staff/resident roster, admissions agreement, pre-placement appraisal, physician’s report, medication administration record, and training records. A tour of the facility.

REPORT CONTINUED IN LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

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-20200624101208

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: 11/12/2020

NARRATIVE

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ALLEGATION: Facility staff harassing resident.

Investigation revealed the following: Based on record review, R1 was admitted to the facility on 4/16/2014. Preplacement Appraisal dated 4/6/2014 shows R1 has symptoms of Major Depression and Bipolar Disorder. Medication Record Administration (MAR) dated 7/2020 indicates R1 is currently taking one tablet of Quetiapine Fumarate 200 mg by mouth twice a day for Schizophrenia, Bipolar Disorder and Depression. Training record dated 7/2/2020 shows facility provides monthly training to Staff on ‘Abuse and Neglect in the Elder Care Setting”, “Respecting Residents Rights” and “Respecting Diversity: Resident, staff and families”.

The Department conducted interviews with Staff (S1- S7) and Residents (R1- R10) from this facility. R1 alleged that S1 verbally harassed her. R1 stated S1 discriminated her based on her race about two years ago. R1 demanded that S1 must apologize to her before the presence of R1’s superior (S7) and be suspended for three months without pay. S7 denied that S1 harassed R1 and he reported that he does not tolerate any act of harassment in the facility. S1 who is the alleged perpetrator denied the allegation. S1 indicated in the interview that she had no clue about this issue and when she heard about it from S7, she attempted to appease R1 but she avoided her in all her attempts. S1-S7 stated no residents have been discriminated or harassed by any facility staff. Interviews with R2-R10 indicated residents are treated with dignity and respect. Based on observation, record review and interviews with S1-S7 and R2-R10, information obtained do not corroborate that S1 harassed R1.

Based on information gathered, LPA did not find sufficient evidence to support the allegation, “Facility staff harassing resident”. This is evidenced by LPA’s observations, interviews and record review.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the complaint investigation of the allegation is UNSUBSTANTIATED.

No deficiency is cited under California Code of Regulations Title 22.

A telephonic exit interview was conducted with Licensee/Administrator Seth Bienstock, and an electronic copy was sent via email for signature.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

LIC9099 (FAS) - (06/04)

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