198204399-3-7-2023-11-AS-EMAZ-CSXVFZ-20230619162445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204399
Report Date: 03/07/2023
Date Signed: 03/07/2023 02:51:47 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
03/03/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20230303152317

FACILITY NAME:	VILLA REDONDO CARE HOME		FACILITY NUMBER:	198204399
ADMINISTRATOR:	MARIA BRAVO		FACILITY TYPE:	740
ADDRESS:	237 REDONDO AVENUE		TELEPHONE:	(562) 434-9931
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90803
CAPACITY:	80	CENSUS: 60	DATE:	03/07/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	ADMINISTRATOR MARIA BRAVO		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff is not providing requested information to Ombudsman Representative regarding resident.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the Villa Redondo Care Home facility on 03/07/2023 at around 09:00 AM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit on 03/07/2023 approximately around 09:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 03/06/2023 and 03/07/2023 LPA Calderon left message for W1 regarding complaint. On 03/07/2023 LPA Calderon requested copies of the following: Contact information on R1-R2, emails between W1 and S1, and any regulations state or federal regarding complaint. On 03/07/2023 LPA Calderon interviewed S1-S2 for complaint.
The investigation revealed the following:

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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-20230303152317

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: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 03/07/2023

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

Regarding Allegation #1: Staff is not providing requested information to ombudsman represented regarding resident.

On 03/06/2023 LPA Calderon reviewed complaint notes. W1 states that W1 department requested contact information on two residents and was denied access to this information by S1 and S2. W1 did not give specifics as to which resident they were requesting the information or why. On 03/07/2023 LPA Calderon interviewed S1 for complaint. S1 states that W1 came to the facility and was requesting contact information on R1-R2. S1 states that S1 advised W1 that they did not have any forwarding information on R1-R2 who had moved out and R2 had passed away. S1 states that they only had a cell phone number for R1. On 03/07/2023 LPA Calderon interviewed S2 for complaint. S2 states that W1 had come to the facility and was requesting contact information on two residents. S2 states that S2 advised W1 that R1 and R2 had moved out and S2 did not have any forwarding information to give W1. S2 states that W1 emailed S2 requesting nonspecific resident information. S2 states that W1 email did not state what exact information W1 was requesting. S2 states that S2 emailed W1 back to advise W1 that S2 needed permission to release resident contact information. S2 email did not deny W1 access to resident information. On 03/07/2023 LPA Calderon reviewed email between W1 and S2 from 01/10/2023 to 01/13/2023. W1 email to S2 and W1 supporting documents do not state what information W1 is requesting and S2 email response states that S2 needs to obtain permission to release contact information. On 03/07/2023 LPA Calderon reviewed records for R1-R2, there is no forwarding information to give W1 other than a cell number for R1.

Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations “staff is not providing requested information to ombudsman representative regarding resident” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D.

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator (S1).

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20230303152317

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: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2023 Section Cited CCR 87468(a)(11)	1 2 3 4 5 6 7	87468 Personal Rights.a) Each resident shall have personal rights which include, but are not limited to, the following: (11) To have his/her visitors, including ombudspersons and advocacy representatives permitted to visit privately during reasonable hours and without prior notice... This requirement is not met as evidenced by	1 2 3 4 5 6 7	Licensee was review the section on personal rights and give additional training to staff on dealing with ombudsman staff by 03/17/2023 and shall provide proof of training to LPA Calderon
	8 9 10 11 12 13 14	Based on Licensing Program Analyst Calderon observation, interviews and record review, the licensee did not comply with the section cited above due not releasing resident 1 and 2 information to ombudsman employee on 01/10/2023. The above which poses an personal rights risk to persons in care.	8 9 10 11 12 13 14
	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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3