198203238-5-12-2023-11-AS-MVAO-CUKKHU-20230810075543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198203238
Report Date: 05/12/2023
Date Signed: 05/12/2023 02:42:31 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
03/18/2021 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210318112136

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:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	Maggie Ornelas - Administrator		TIME COMPLETED:	03:24 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple pressure injuries while in care.

INVESTIGATION FINDINGS:

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

On 05/12/2023, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced subsequent complaint visit at this facility. LPA was met by Maggie Ornelas, Administrator, and explained the purpose of the visit to deliver findings for the allegation mentioned above.
On 03/18/2021 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegation listed above. A plant inspection of the facility was conducted. LPA requested copies of the following documents: client roster, staff roster, admission agreements, needs and service plans, face sheets, ID/Emergency information, physician reports, and medication administration reports for the last 3 months for residents’ R1 and R2. The Investigation Branch's Department conducted interviews with the staff S1 through S5 and witness (W1). The Investigation Branch’s Department also obtained medical records and other pertinent documents were reviewed.

See 9099-C

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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-20210318112136

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: SOUTH BAY SENIOR LIVING	FACILITY NUMBER: 198203238
	VISIT DATE: 05/12/2023

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:

Regarding the allegation “Resident sustained multiple pressure injuries while in care”. Resident records indicate that R1 was admitted to this facility on 05/16/2019. Hospital medical records indicate that on 10/10/2020 R1 was diagnosed with Stage 2 pressure injuries to the right Sacrum that measured 2.5 x 1.5 cm and left Sacrum that measured at 1 x 1 cm. And on 03/23/2021, resident (R1) was diagnosed with a stage 3 pressure injuries on the sacrum/coccygeal that measured at 1.5 x 0.4 x 0.6 cm and an Unstageable pressure injury on the right heel that measured 1.5 x 2 x 3 cm. Staff interviews revealed that staff provided wound care with no hospice or wound care involved. During the interviews with staff, the Administrator admitted to retaining resident (R1) without proper medical attention/professionals staging the pressure sores; R1 needed a higher level of care and supervision. There was no hospice or wound care involved in resident’s (R1) care and supervision at the facility. Based on the interviews conducted with staff (S1-S5) and witness (W1), there is sufficient evidence that resident (R1) was neglected and not given the proper level of care and supervision; therefore, the allegation is substantiated.

Based on the Department’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “Resident sustained multiple pressure injuries while in care " is found to be: "Substantiated".

An exit interview conducted with Administrator Maggie Ornelas and a hard copy of the report was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20210318112136

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: SOUTH BAY SENIOR LIVING	FACILITY NUMBER: 198203238
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/15/2023 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615 Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 or 4 pressure injuries.	1 2 3 4 5 6 7	87615(a)(1) The licensee agreed to read, sign and date Title 22, Section 87615(a)(1) “Prohibited Health Conditions” that she understands this section.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on LPA observation, record reviews and interviews conducted, resident (R1) developed stage 3 pressure injuries while in care which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	The Licensee also agrees to conduct an in-service staff training to ensure future compliance with the reporting of physical changes in the residents' condition.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3