198201933-8-3-2023-11-AS-JHAD-CWVW59-20231023165845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201933
Report Date: 08/03/2023
Date Signed: 08/03/2023 03:25:31 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
07/20/2023 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20230720120421

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: 89	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	LVN Angelica Padilla		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff are not intervening in resident to resident arguments.

INVESTIGATION FINDINGS:

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On 08/03/23 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Administrator, Linda Cardenas as the purpose of today’s visit was explained.
The investigation consisted of the following: On 07/27/23 LPA interviewed Administrator Linda Cardenas (A1) and interviewed residents # 1-2(R1-R2). LPA obtained copies of R1's and R2’s Facesheets, appraisals, needs and service plans, physician’s reports, med lists, admissions agreements. On 7/28/23, LPA interviewed Licensee Seth Bienstock (L1).
The investigation revealed the following: On 07/27/23 LPA interviewed Administrator Linda Cardenas regarding the above allegation, Administrator denied the allegation above. Administrator stated that both residents have feisty attitudes and that she (A1) has spoken to both residents to remind them of facility rules. Administrator also reported that R1 has been spoken to and redirected when R1 has interfered when staff is attempting to provide care for R2. Administrator stated that R1 was offered a room change but responsible party for R1 declined room change.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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-20230720120421

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: 08/03/2023

NARRATIVE

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On 7/27/23 LPA interviewed R1-R2, per R1, R2 is terrible and has outburst when staff attempts to provide care. R1 reports she has attempted to step in when R2 yells at staff but ends up getting yelled at even more. R1 reports she feels safe but will switch rooms if there’s a room available. R1 stated R1 informed staff of R2 behavior but there was nothing staff can do to that being R2s behavior. R2 reports that her interactions with R1 are rocky as they do not get along, R2 reports that R1 yells at her all the time and would like for R1 to be moved from the shared room. R2 stated that R2 informed staff about R1s behavior and stated that staff did not do anything.

On 7/28/23, LPA interviewed Licensee Seth Bienstock (L1). who denied the above allegations, per L1 residents have reported arguments they have with roommates but never have residents reported any abuse. L1 continued to state that when room changes are an option when a room is available but was unaware that a room change was needed for the residents in question. Per L1, a room change will be discussed with residents #1-2.

On 7/28/23 LPA Villegas attempted to interview R2’s responsible party but there was no answer or call back.

On 8/3/23 LPA Villegas interviewed Staff #1-2 (S1-S2), S1 and S2 denied the above allegation. S1 reported that R1 has a good relationship with staff and steps in too their defense when R2 is yelling or hits staff. S1 reports that when R1 starts to speak about R2’s attitude R2 becomes triggered and starts to name call. S1 states staff has asked R1 not to step in and to let staff handle R2’s behavior, R1 complies. S2 reports that she has not observed any altercations with R1 and R2 but would intervene and separate the residents if it was observed. Per S2, R2’s behavior changes and tends to refuse 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.

Exit interview conducted to with Administrator Linda Cardenas and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230720120421

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: 08/03/2023

NARRATIVE

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On 7/27/23 LPA interviewed R1-R2, per R1, R2 is terrible and has outburst when staff attempts to provide care. R1 reports she has attempted to step in when R2 yells at staff but ends up getting yelled at even more. R1 reports she feels safe but will switch rooms if there’s a room available. R1 stated R1 informed staff of R2 behavior but there was nothing staff can do to that being R2s behavior. R2 reports that her interactions with R1 are rocky as they do not get along, R2 reports that R1 yells at her all the time and would like for R1 to be moved from the shared room. R2 stated that R2 informed staff about R1s behavior and stated that staff did not do anything.

On 7/28/23, LPA interviewed Licensee Seth Bienstock (L1). who denied the above allegations, per L1 residents have reported arguments they have with roommates but never have residents reported any abuse. L1 continued to state that when room changes are an option when a room is available but was unaware that a room change was needed for the residents in question. Per L1, a room change will be discussed with residents #1-2.

On 7/26/23 LPA Villegas interviewed reporting party, R1’s daughter about the above allegation. Per reporting party, R1 has reported that she is verbally abused by R2 daily and staff is not assisting. Reporting party stated she does not want R1 to be changed from her current room and would prefer to have R2 moved as she believes there are other rooms available for R2.

On 7/28/23 LPA Villegas attempted to interview R2’s responsible party but there was no answer or call back.

On 8/3/23 LPA Villegas interviewed Staff #1-2 (S1-S2), S1 and S2 denied the above allegation. S1 reported that R1 has a good relationship with staff and steps in too their defense when R2 is yelling or hits staff. S1 reports that when R1 starts to speak about R2’s attitude R2 becomes triggered and starts to name call. S1 states staff has asked R1 not to step in and to let staff handle R2’s behavior, R1 complies. S2 reports that she has not observed any altercations with R1 and R2 but would intervene and separate the residents if it was observed. Per S2, when sun downing R2’s behavior changes and tends to refuse care, R2 can be combative usually during the night shift.

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.
Exit interview conducted to LVN Angelica Padilla and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

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