198201933-10-4-2023-11-AS-MVAO-CY7VGC-20231204152520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201933
Report Date: 10/04/2023
Date Signed: 10/04/2023 03:23:02 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
09/26/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20230926112128

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:	10/04/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Linda Cardenas, Admin Assistant		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not prevent a resident from mistreating another resident while in care

INVESTIGATION FINDINGS:

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On 10/4/23 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived at 9am and spoke to Med Technician Supervisor, Ernestine Cunningham and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following: On 10/4/23 LPA reviewed Resident files and toured the facility. LPA reviewed and requested copies of the following records: Client Roster, Staff roster, resident files, incident reports for the month of September, Palos Verdes Villa House Rules.

The investigation revealed the following:

Cont'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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-20230926112128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALOS VERDES VILLA LLC	FACILITY NUMBER: 198201933
	VISIT DATE: 10/04/2023

NARRATIVE

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The investigation revealed the following:

Allegation: Facility does not prevent a resident from mistreating another resident while in care.

On 10/4/2023 at 10am LPA Shirley reviewed facility files and documentation. During document review, LPA reviewed incident reports and did not find any reports of harassment. LPA reviewed house rules, “Palos Verdes Villa, Your Home on the Hill”, #5) Excessive drinking, abusive language and antagonistic behavior toward other residents will not be tolerated. Respect others as well as their property. This agreement is signed by all residents upon admission.

On 10/4/23 from 11am to 12:00pm LPA Shirley interviewed staff 1 - staff 9 (S1 - S9). LPA asked staff if they have witnessed any types of harassment here at this facility. Of those interviewed, 9 out of 9 staff felt that there is no claims or history of harassment here at this facility. On 10/4/23 from 12:00pm to 1:00pm LPA Shirley interviewed residents 2 – residents 9 (R2 - R9). R1 was contacted but refused to be interviewed. LPA asked if anyone has ever been harassed or bullied. Based on interviews, 8 out of the 8 stated that they have never witnessed any type of harassment at this facility.

Based on information gathered, the department did not find sufficient evidence to support allegations "Facility staff do not prevent a resident from mistreating another resident while in care.” 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 allegation is Unsubstantiated.

An exit interview was conducted and a copy of the LIC 9099 was provided to Administrator Assistant Linda Cardenas.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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