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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198201977
Report Date: 10/27/2023
Date Signed: 10/27/2023 02:45:19 PM

Substantiated


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
10/17/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20231017091618
FACILITY NAME:SANCTUARY, THEFACILITY NUMBER:
198201977
ADMINISTRATOR:CATHERINE RAYMUNDOFACILITY TYPE:
740
ADDRESS:21410 MADRONA AVENUETELEPHONE:
(424) 558-3134
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 3DATE:
10/27/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Catherine Raymundo/AdministratorTIME COMPLETED:
02:44 PM
ALLEGATION(S):
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Improper Eviction
INVESTIGATION FINDINGS:
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On 10/27/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Catherine Raymundo /Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Client’s interviews (R#1-R#4), Staff Interview (S#1) and Reporting Party interview (RP). LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, (R#1-R#4) Identification and Emergency Information, (R#1-R#4) Admissions agreements, (R#1-R#4) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#4) Needs and Services Plan, (R#1-R#4) Medication Administration Record (MAR) for the month of October 2023 and copy of (R#1) Eviction Noticed dated on 8/24/2023.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
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 9
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
10/17/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20231017091618

FACILITY NAME:SANCTUARY, THEFACILITY NUMBER:
198201977
ADMINISTRATOR:CATHERINE RAYMUNDOFACILITY TYPE:
740
ADDRESS:21410 MADRONA AVENUETELEPHONE:
(424) 558-3134
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 3DATE:
10/27/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Catherine Raymundo/AdministratorTIME COMPLETED:
02:44 PM
ALLEGATION(S):
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9
Facility staff failed to provide nurtious and well balanced meals to residnets.
Facility staff failed to address residents significant weight gain.
Facility staff failed to notify residnets authorized representative of a change in condition.
INVESTIGATION FINDINGS:
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On 10/27/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with /Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Client’s interviews (R#1-R#4), Staff Interview (S#1) and Reporting Party interview (RP). LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, (R#1-R#4) Identification and Emergency Information, (R#1-R#4) Admissions agreements, (R#1-R#4) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#4) Needs and Services Plan, (R#1) Medication Administration Records (MAR) from April-October 2023, (R#2-R#4) Medication Administration Record (MAR) for the month October 2023, copy of schedule of medications for (R#1), copy of Medical evaluation from CareMore dated on 8/23/202, Inspection of perishable and non-perishable food items at the facility and copy of (R#1) Eviction Noticed dated on 8/24/2023.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 11-AS-20231017091618
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: SANCTUARY, THE
FACILITY NUMBER: 198201977
VISIT DATE: 10/27/2023
NARRATIVE
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Investigation Revealed the Following:

Allegation(s):

Facility staff failed to provide nutritious and well-balanced meals to residents.

The details of the complaint alleged that facility staff failed to provide well-balanced and nutritious meals to residents in care.



During an Interview with the Administrator (A#1), she stated that the residents get three meals per day: breakfast, lunch, and dinner plus snacks during the day. Also, (A#1) stated that the meals they served to the residents were well-balanced and nutritious, “we served a variety of vegetables with protein in our meals.

During interviews with Residents (R#1-R#4), they stated that 3 out of 4 stated that the facility serves them three meals per day: breakfast, lunch, and dinner, plus snacks during the day. In addition, 3 out of 4 stated that the meals the facility serves are well-balanced and nutritious.

During interviews with Staff (S#1), she stated that the residents are getting three meals daily: breakfast, lunch, and dinner, plus snacks are available if the residents request some. In addition, (S#1) stated that the meals the facility serves to the residents are well-balanced and nutritious, “we served vegetables in their meals” (S#1) said.

Allegation(s):

Facility staff failed to address residents’ significant weight gain.

The details of the complaint alleged that the facility failed to address significant weigh gain.




Evaluation Report continues LIC 9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 11-AS-20231017091618
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: SANCTUARY, THE
FACILITY NUMBER: 198201977
VISIT DATE: 10/27/2023
NARRATIVE
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During the records review, LPA Iniguez reviewed (R#1)’s medical evaluation from CareMore dated 8/23/2023. The assessment states that that day, a caregiver from the board and care where she lives was present at the appointment. In addition, the medical evaluation states that (R#1) appetite has increased due to a secondary reaction to the medication (R#1) is currently taking. In addition, LPA reviewed (R#1)’s Medication Administration Records (MAR) from April to October 2023; LPA observed that (R#1) has been taking the medication since they came to the facility; this medication has a secondary reaction of increased appetite and weight gain based on the medical evaluation report from CareMore dated on 8/23/2023. Moreover, LPA observed admissions documents from Bel Air Congregated Living Nursing Home; these documents are dated 4/2/2023. The papers state that (RP) was informed by MD of the risks and benefits of (R#1)’s medications.

During an Interview with the Administrator (A#1), she stated that the facility serves ice cream for dessert to give to the residents, but the facility does not serve ice cream three times per day every day.

During interviews with Residents (R#1-R#4), 3 out of 4 stated that the facility serves them ice cream for dessert once daily. Also, 3 out of 4 states that the facility only serves them ice cream three times per day.
During interviews with Staff (S#1), she stated that the facility serves ice cream to residents only once and not three times per day. Also, (S#1) stated that (R#1-R#4) did not gain weight because they ate ice cream thrice daily.
Allegation(s):

Facility staff failed to notify residnets authorized representative of a change in condition.



The details of the complaint alleged that the facility staff failed to notify residents authorized representative of a change in condition.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 11-AS-20231017091618
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: SANCTUARY, THE
FACILITY NUMBER: 198201977
VISIT DATE: 10/27/2023
NARRATIVE
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During the records review, LPA Iniguez reviewed (R#1) 's Medical Evaluation performed at CareMore clinic dated 8/23/2023; it is listed that the people present at the medical appointment was (R#1) and a staff from the facility where (R#1) currently lives. Also, the plan from the Nurse Practitioner who evaluated (R#1) on 8/23/2023 states that (R#1) requires a higher level of care as her dementia requires continuous medical supervision.in addition, LPA reviewed (R#1) 's Appraisal/Needs and Service Plan (LIC 625) form dated 4/15/2023. In the Physical Health tab, it is documented that (R#1) is ambulatory with one person assist. Sometimes, the staff puts her in a wheelchair if their gait is not stable. In addition, LPA reviewed (R#1) 's Physician Report for the Residential Care Facilities for the Elderly (RCFE) form LIC 602A. The ambulatory state for (R#1) is non-ambulatory due to a mental condition.

During an Interview with the Administrator (A#1), she stated that she keeps progress notes for the residents at the facility and she documents the resident's physical and emotional changes. (A#1) stated that she has never failed to document physical and emotional changes in the residents. In addition, (A#1) stated that when physical or mental changes occurred in the residents, she informed their appropriate representatives and physicians. In addition, (A#1) stated that (R#1) was able to walk with assistance, and (A#1) stated that when (R#1) took their medications, their gait was not stable. (A#1) stated that (R#1) always complained about knee pain. (A#1) also stated that when (R#1) came to live at the facility, (RP) told us about their knee problems.

During interviews with Residents (R#1-R#4), 3 out of 4 stated that the facility monitors their physical and emotional changes correctly, and they feel the facility will inform their representatives about their medical changes.

During interviews with Staff (S#1), she stated that the facility monitors and documents the resident's physical and emotional changes, and when a change happens to one of the residents, the facility will inform their representatives.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 11-AS-20231017091618
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: SANCTUARY, THE
FACILITY NUMBER: 198201977
VISIT DATE: 10/27/2023
NARRATIVE
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During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

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.


California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of the Complaint Report was given to Catherine Raymundo /Administrator Designee.


SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 11-AS-20231017091618
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: SANCTUARY, THE
FACILITY NUMBER: 198201977
VISIT DATE: 10/27/2023
NARRATIVE
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Investigation Revealed the Following:

Allegation(s): Improper Eviction

The details of the complaint alleged that facility served an improper eviction to one of the residents.


During the records review, LPA Iniguez reviewed the Evaluator Manual/Senior Care/RCFE/ Section 87224-Eviction Procedures paragraph (a): The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as specified in paragraph (5). In addition, LPA reviewed the eviction letter the facility gave to (RP); the letter is dated 8/24/2023. It is addressed to (RP), who says that (R#1) needs a higher level of care due to their medical conditions. When the facility admitted (R#1), they took care of them, but due to the need for higher medical care (R#1), the facility decided to serve (RP) a 60-day notice eviction letter. The last day for (R#1) to remain at the facility was 10/23/2023. (R#1) left the facility on 10/15/2023.

During the Interview with (RP), she stated that on 8/24/2023, the facility gave them a 60-day eviction notice. (RP) said that the facility told them they needed to look for another place for (R#1).

During an Interview with the Administrator (A#1), she stated that on 8/24/2023, she served a letter of eviction to (R#1), (A#1) did not let CCLD or waited for their approval. I gave (RP) a 60-day notice eviction letter on 8/24/2023. LPA asked (A#1) if she gave a copy of the eviction letter to CCLD, and she said not. On 10/27/2023, during the 10-day visit, LPA told (A#1) to fax a copy of the eviction letter to RO.

During interviews with Staff (S#1), she stated that she is familiar with the eviction procedures, and she knows that the facility gave an eviction letter to (R#1).

During interviews with Residents (R#1-R#4), 3 out of 4 stated that the facility has yet to give them an eviction letter in the past.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 11-AS-20231017091618
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: SANCTUARY, THE
FACILITY NUMBER: 198201977
VISIT DATE: 10/27/2023
NARRATIVE
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During this investigation, LPA found sufficient evidence to support the above-mentioned allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.

An exit interview was conducted, and a copy of the Complaint Report was given to Catherine Raymundo/Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 11-AS-20231017091618
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: SANCTUARY, THE
FACILITY NUMBER: 198201977
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2023
Section Cited
CCR
87224(f)
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87224 Eviction Procedures
(f) A written report of any eviction shall be sent to the licensing agency within five (5) days.
This requirement was not met as evidence by:
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Administrator will re-write eviction letter and will send it to evicted party and to CCLD. Administrator will do this before POC due date.
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Based on a review of records and interviews, the facility administrator failed to notified CCLD about the eviction letter given to (R#1) and (RP).
This poses a potential health and safety risk to all residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 9 of 9