198201933-5-9-2022-11-AS-JHAD-CER22B-20220524170025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201933
Report Date: 05/09/2022
Date Signed: 05/09/2022 01:40:59 PM

Unsubstantiated

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
12/17/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20211217112114

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: 94	DATE:	05/09/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	ADMINISTRATOR LINDA CARDENAS		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff did not give resident medications as prescribed.
Facility staff blamed resident for not calling when they were not given their medications.
Facility staff did not give resident a Band-Aid upon request.
Facility does not have sufficient staff to meet the needs of the residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility on 05/09/2022 at 09:00 AM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. S1 informed LPA that the facility has 2 COVID cases to staff and were sent home a week ago. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10 day visit on 12/21/21 approximately 09:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 12/21/2021 LPA Calderon requested copies of the following: staff and residents’ roster, SIR reports (for current complaint), physician’s report, appraisal/needs and service plan, and all medical records to include any hospital records for Resident #1. On 12/21/2021 LPA Calderon interviewed S1 – S6 for complaint and on 12/21/2021 and 05/09/2022 LPA Calderon interviewed R1 – R10 for complaint. On 12/21/2021 LPA Calderon interviewed W1 for complaint.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

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 3

Control Number 11-AS-20211217112114

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: PALOS VERDES VILLA LLC	FACILITY NUMBER: 198201933
	VISIT DATE: 05/09/2022

NARRATIVE

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Regarding Allegation #1: Facility staff did not give resident medications as prescribed. On 12/21/2021 LPA Calderon interviewed W1 who stated that R1 had advised that the facility was not providing medication as prescribed. On 12/21/2021 LPA Calderon interviewed R1 who stated that staff did not give medication on time and in the right amount and were not following the doctor’s orders. On 12/21/2021 LPA Calderon interviewed S1 – S6 who all stated that they follow doctors’ orders in giving medication to residents, and update residents MAR to address when medication is given and in what amount. Staff state that if a resident refuse to take medication or they miss giving the medication to the resident this is documented in the resident medical records. On 12/21/2021 and 05/09/2022 LPA Calderon interviewed R2 – R10 all residents state no issues with medication provided by staff. On 12/21/2021 LPA Calderon reviewed Needs and Service Plan, Physician Report, MAR for R1, medical records state that staff did not miss or forget to give medication to R1.

Regarding Allegation #2: Facility staff blamed resident for not calling when they were not given their medication. On 12/21/2021 LPA Calderon interviewed W1 who stated that R1 advised that facility staff blamed R1 when medication was missed or not given at the right time. On 12/21/2021 LPA Calderon interviewed R1 who stated that staff missed giving medication and blamed R1 who should have informed staff of any medication issues. On 12/21/2021 LPA Calderon interviewed S1 – S6 who all stated that they would never blame a resident for issues with medication and if there are issues with a resident medication, they update all records. On 12/21/2021 and 05/09/2022 LPA Calderon interviewed R2 – R10 all residents state no issues with staff advising them of their medication status and never have staff blamed residents for any issues.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20211217112114

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: PALOS VERDES VILLA LLC	FACILITY NUMBER: 198201933
	VISIT DATE: 05/09/2022

NARRATIVE

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Regarding Allegation #3: Facility staff did not give resident a band-aid upon request. On 12/21/2021 LPA Calderon interviewed W1 who had no proof staff refused to give a band aid to resident. On 12/21/2021 LPA Calderon interviewed R1 who stated her finger was bleeding and R1 walked to the medication room. R1 states that staff in the room refused to give R1 a band-aid upon request. On 12/21/2021 LPA Calderon interviewed S1 – S6 who state that no medical help is ever refused to a staff, resident or guest upon request and they keep records of such request from a resident. On 12/21/2021 and 05/09/2022 LPA Calderon interviewed R2 – R10 who all state that they have never been refused medical attention and over time have cut a finger and given a band-aid upon request. On 12/21/2021 LPA Calderon reviewed medical records for R1, there is no record of R1 requesting a band-aid for a cut finger.

Regarding Allegation #4: Facility does not have enough staff to meet the needs of the residents. On 12/21/2021 LPA Calderon interviewed W1 who did not have any proof that the facility did not have enough staff working. On 12/21/2021 LPA Calderon interviewed R1 who stated that R1 must wait for medication service, and when R1 calls the front desk at night no staff answers the phone. On 12/21/2021 LPA Calderon interviewed S1 – S2, administrator and licensee both states no staffing issues. On 12/21/2021 LPA Calderon interviewed S3 – S6 who all state that there could be more staff hired, but no resident must wait more than 5 to 10 minutes for help, resident is never refused help by staff and there is enough staff to help residents in need. On 12/21/2021 and 05/09/2022 LPA Calderon interviewed R2 – R10, all residents state to have no knowledge of any staffing issues and state no issues with services provided by staff. On 12/21/2021 LPA Calderon reviewed staff vs resident rosters and it would appear there is enough staff to help with resident’s needs.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of Facility staff did not give resident medications as prescribed. Facility staff blamed resident for not calling when they were not given their medications. Facility staff did not give resident a Band-Aid upon request. Facility does not have enough staff to meet the needs of the residents is found to be UNSUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report was provided to the Administrator (Linda Cardenas).

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

LIC9099 (FAS) - (06/04)

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