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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198203238
Report Date: 10/24/2020
Date Signed: 10/24/2020 10:13:26 AM



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
06/23/2020 and conducted by Evaluator Jennifer Jones
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200623113600
FACILITY NAME:SOUTH BAY SENIOR LIVINGFACILITY NUMBER:
198203238
ADMINISTRATOR:MAGGIE ORNELASFACILITY TYPE:
740
ADDRESS:22711 S. VERMONT AVE.TELEPHONE:
(310) 320-3318
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY:70CENSUS: 39DATE:
10/24/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maggie Ornelas, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident sustained multiple falls while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Jones initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Maggie Ornelas the facility Administrator.

During the call, LPA Jones interviewed the administrator, Maggie Ornelas about the current allegation. LPA Jones requested the facility staff roster and staff schedule, resident roster, R1's identification form, admissions agreement, physician's report, reappraisal and incident reports for R1.

On 10/24/20, LPA delivered findings to the administrator, Maggie Ornelas. The investigation revealed the following: For allegation (Resident sustained multiple falls while in care). It was alleged that resident 1 has fell on three different occassions and is in need of addional supervision. On 06/30/20, the administrator admitted to LPA Jones that R1 has fallen on numerous occassions or slid out of her wheel chair at the
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2020
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-20200623113600
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: SOUTH BAY SENIOR LIVING
FACILITY NUMBER: 198203238
VISIT DATE: 10/24/2020
NARRATIVE
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facility. The administrator stated that all of the caregivers conduct routine room checks every couple of hours on all residents in the facility. The administrator stated that R1 needs assistance with some ADLs(dressing, grooming and bathing). The administrator stated that R1 has gotten out of bed without assistance and dresses herself but there has also been cases when R1 has fallen as result. The administrator said R1 utilizes the pull string to notify caregivers when she has fallen down or slid out of her wheel chair. The administrator stated that she was not aware of R1 sustaining any falls in the past due to her having a private care giver until the end of 2019. The administrator stated that after R1 no longer has the private caregiver, she began to witness R1 having falls. On 07/01/20, Staff 2 and 3 revealed to LPA that they directly assist R1. Staff 2 and 3 stated that have witnessed R1 sustain multiple falls and feels that R1 needs additional care. Staff 2 and 3 stated that R1 calls for help more often than the other residents. The administrator stated that have not conducted a reappraisal on R1 to consider if she needs more care. Staff 4 and 5 stated that they have assisted R1 but never witnessed her fall. LPA attempted to interview R1 but was unable to get a response. On 07/01/20, Residents 2 stated that he observed R1 on her back calling for help 4 months ago. R3-R5 said they know R1 but never witnessed or heard of her falling. R1's family member stated that she is aware of R1's falls but said R1 will make herself fall to get more attention from the facility staff.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Maggie Ornelas, Administrator and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20200623113600
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: SOUTH BAY SENIOR LIVING
FACILITY NUMBER: 198203238
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2020
Section Cited
CCR
87463(a)
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The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Requirement is not met as evidence by: Administrator failed to
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Administrator will send LPA a copy of the reappraisals and care plan in place for resident. Administrator will send by POC due date
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reassess R1 after multiple falls.
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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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2020
LIC9099 (FAS) - (06/04)
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