198203238-3-23-2022-11-AS-MVAO-CDVSA8-20220427134156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198203238
Report Date: 03/22/2022
Date Signed: 03/23/2022 07:08:48 AM

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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/17/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220317151816

FACILITY NAME:	SOUTH BAY SENIOR LIVING		FACILITY NUMBER:	198203238
ADMINISTRATOR:	MAGGIE ORNELAS		FACILITY TYPE:	740
ADDRESS:	22711 S. VERMONT AVE.		TELEPHONE:	(310) 320-3318
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY:	70	CENSUS: 35	DATE:	03/22/2022
		UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	MAGGIE ORNELAS		TIME COMPLETED:	04:17 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident is wearing soiled clothing.
Resident's hygiene needs are not being met.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 03/22/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Maggie Ornelas administrator. LPA explained the purpose of today's inspection visit and to collect information.

The investigation consisted of the following: A review of the roster for residents and staff. A review of resident #1 (R1's) service records. Interview conducted with staff #1-#5 (S1-S5), residents #1-#6 (R1-R6), and witness #1-#2 (W1-W2) A tour of the entire facility was inspected.

Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

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-20220317151816

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
MONTERY PARK, CA 91754

FACILITY NAME: SOUTH BAY SENIOR LIVING	FACILITY NUMBER: 198203238
	VISIT DATE: 03/22/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident is wearing soiled clothing.
Resident's hygiene needs are not being met.

It is alleged resident #1 (R1) was in soiled clothing and that her hygiene her needs are not being met. (R1) was admitted on 03/14/22 to Harbor UCLA Medical Center due to chest and abdominal pains. The complainant unable to provide additional details on these allegations, states (R1) showered minimally and is left in soaked undergarments.

The Department interviewed (R1) and self-proclaimed she is independent. (R1) states she is able to bathe, dress, groom, feed and use the toilet on her own. (R1) claims she uses incontinence pads that she is able to manage on her own. (R1) disputes being in soiled clothing on 03/14/22 and states she never left in soiled clothing or briefs. (R1) claims the staff is quick to assist if she needs help with her activities of daily living (ADLs). An interview with witness #1 (W1) power of attorney and family member, describes the staff at this facility as genuine, caring, compassionate, responsive, and accommodating. (W1) verified (R1) is independent and still makes decisions on her own. (W1) states she is a headstrong independent individual. (R1) will often refuse help with personal hygiene and grooming from the staff. An interview with witness #2 (W2) nurse for Legend Home Health states she comes out to visit three (3) times a week to service (R1). (W2) reports that (R1) is unwilling to accept help from anyone. (W2) who was present on 03/14/22 during (R1’s) transport to the hospital argues (R1) was not in soiled clothes or undergarments when she left the facility. Interviews with staff #1-#5 (S1-S5) report that (R1) is prompted daily and will often decline help with her personal care. The Department examined the facility’s shower records and found the information was entered and that logs were in order. The records revealed (R1) on several occasions refused to shower. Interviews conducted with resident #2-#6 (R2-R6) reports the staff is attentive when it comes to their care. Furthermore, (R2-R6) claims the staff provides more than adequate services and is complimentary of them. The Department observed (R1) did not appear unkempt or present with an unpleasant smell from soiled clothes or undergarments. A review of (R1's) physician's orders verified she is capable of self-care with personal hygiene practices. (S1) states after this hospitalization, she will consult with (R1’s) POA and primary physician for an up-to-date medical assessment of the resident.

Evaluation Report continues on LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20220317151816

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
MONTERY PARK, CA 91754

FACILITY NAME: SOUTH BAY SENIOR LIVING	FACILITY NUMBER: 198203238
	VISIT DATE: 03/22/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on information gathered, an inspection of the facility, observation, analysis of (R-1)'s service records, incident report, and interviews conducted, the Department found no evidence to support the allegations listed on this complaint report.

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.

An exit interview was conducted with Maggie Orneles and a copy of the report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3