198203238-8-2-2023-11-AS-EMAZ-CUKNZU-20230810105451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198203238
Report Date: 08/02/2023
Date Signed: 08/02/2023 11:44:02 AM

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
11/22/2022 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221122135446

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: 39	DATE:	08/02/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administrator Maggie Ornelas		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not administer residents medications.
Staff are inappropriately recording resident.
Staff did not provide resident with his wheelchair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Administrator (A1: Maggie Ornlas). LPA/RA conducted a risk assessment prior to entering facility. A1 informed LPA/RA that the facility has no COVID cases nor do the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations.

An initial 10-Day visit was conducted by LPA Maressa Brown on 12/01/22 with Asst. Administrator (A2: James Simms). During this visit, LPA Brown reviewed the following documents and obtained copies: Resident #1 (R1) and Resident #2 (R2) admission agreement, identification and emergency information, physician's report, medication administration reports (November 2022); staff & resident rosters, and facility staff training records. RA Ceniceros attempted two telephone calls to Witness #1 and call back from Staff #3 but to no avail.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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-20221122135446

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: 08/02/2023

NARRATIVE

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Regarding Allegation #1: this investigation revealed based on interviews conducted of Staff #1- #5 S1–S5) 4 of 5 corroborated that Resident #1 (R1) is administered medications as prescribed by the resident’s physician’s orders. The med techs have not received a complaint from a resident that their medication(s) was not administered, nor a resident being ignored when asking for their medication(s). Interviews conducted of Resident #2 – Resident #3 corroborated that the med techs administer their medication(s) according to their physician’s orders in the morning, afternoon, evening, and/or bedtime. Residents have not experienced an issue with the med techs ignoring them whenever they’ve requested for their medication(s). A review of Resident #1’s medication administration record documented (via initials) that on 11/20/22, Resident #1 was administered their medications during all shifts: by Staff #1 (A.M. Med Tech), Staff #2 (P.M. Med Tech) and Staff #3 (NOC Med Tech). A review of the med techs training records documented that they received medications training on 03/05/21.

Based on the evidence gathered and interviews conducted, and records reviewed, 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 of MEDICATION: Staff did not administer residents medications is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on interviews conducted of Facility Staff #1-#5 (S1– S5) 4 of 5 corroborated that they had not witnessed a staff member recording Resident #1 nor received a complaint from a resident that they were being recorded by a staff member. Facility staff are aware of a policy regarding no audio recording, video or taking of pictures is allowed inside the facility without the permission of a resident. Interviews conducted of Residents #2 - #3 (R2 – R3) acknowledged that audio recording, video or taking of pictures without authorization is a violation of the resident’s privacy. There was no interview with Resident #1 during the initial 10-Day visit; as the resident was in a skilled-nursing facility. During the subsequent visit, Resident #1 had not returned to the facility, effective 02/01/23. RA Ceniceros toured the facility and observed three (3) cameras situated in the hallways (photos). RA did not observe cameras or recording devices inside residents’ Room #146 or Room #148. A review of facility staff training records documented that they received residents rights training on 04/19/19.

Based on the evidence gathered, interviews conducted, and records reviewed, 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 of PERSONAL RIGHTS: Staff are inappropriately recording resident is found to be UNSUBSTANTIATED.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20221122135446

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: 08/02/2023

NARRATIVE

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Regarding Allegation #3: this investigation revealed based on interviews conducted of Facility Staff #1-#5 (S1– S5) 4 of 5 corroborated they had not witnessed a staff member ignoring Resident #1 while struggling to stand up and request for their wheelchair. Facility staff are aware and acknowledge that they are mandated reporters and that they had not received a complaint from a resident that facility staff was ignoring them and would walk right past them when they would request for their wheelchair. Interviews conducted of Residents #2 - #3 (R2 – R3) acknowledged that they had not observed a facility staff member ignore a resident - while the resident was struggling to stand up in their wheelchair – that a staff member just passed them by and did not assist the resident with their wheelchair. A review of facility staff training records documented that they received mandated reporting training on 12/19/22.

Based on the evidence gathered, interviews conducted, and records reviewed, 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 of PERSONAL RIGHTS: Staff did not provide resident with his wheelchair is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Administrator (Maggie Ornelas).

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC9099 (FAS) - (06/04)

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