198204399-10-2-2023-11-AS-MVAO-CWVVSL-20231023164142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204399
Report Date: 09/28/2023
Date Signed: 10/02/2023 09:20:30 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
12/14/2022 and conducted by Evaluator Lizeth Villegas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221214153652

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: 67	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Assistant Administrator David Hernandez		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff failed to meet resident's medical needs
Staff failed to properly assess resident before accepting
Staff failed to seek medical attention for resident in a timely manner
Staff failed to administer resident's medication as prescribed
Staff failed to provide appropriate transportation for resident
Staff refused to assist resident while in care
Staff failed to assist resident with showers

INVESTIGATION FINDINGS:

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On 09/28/23 at 8:30 am Licensing program analyst (LPA) Lizeth Villegas and Licensing analyst manager (LPM) Janae Hammond conducted a subsequent complaint visit to render investigation finding. LPA met with Assistant Administrator David Hernandez as the purpose of today’s visit was explained.

The investigation consisted of the following: On 09/28/2023 LPA obtained copies of Staff and resident roster, R1's face sheet, emergency I.D. form, Physician's order, shower refusal form (01/12/23), Preplacement appraisal, individualized service plan, Resident assessment form, unusual incident reports, receipt of controlled substances and Admission agreement. On 09/28/23 LPA and LPM interviewed Staff #1-6 (S1-S6), and Residents #2-8. On 09/26/23 LPA attempted to interview R1 but was unsuccessful.

The investigation revealed the following: Allegation: Staff failed to meet resident's medical needs
It is alleged that R1 had diarrhea for 3 weeks and it is not being adressed by facility staff, it is also being alleged that staff are not conducted blood pressure checks for R1. On 09/28/23 at 8:45 am LPA and LPM interviewed staff # 1-6 (S1-S6), 6 of the 6 staff interviewed denied the allegation above and

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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-20221214153652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 09/28/2023

NARRATIVE

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indicated residents needs are being met. On 09/28/23 at 9:30 am LPA and LPM interviewed residents #2-8 (R2-R8) 7 of 7 residents interview denied the allegation. LPA and LPM reviewed R1's file and checked physician's orders, medication list ,resident assessment form and pre appraisal form which reveled there is no documented physician's orders indicating resident requires blood pressure checks and there is no indication that resident has diarrhea for consecutive weeks.

Allegation: Staff failed to properly assess resident before accepting.
It is being alleged that staff failed to properly assess resident before being accepted into the facility. On 09/28/23 LPA and LPM interviewed staff # 1-6 (S1-S6), 6 of the 6 staff interviewed denied the allegation and reported that staff will go out to conduct assessment prior to admission. On 09/28/23 LPA and LPM interviewed residents #2-8 (R2-R8) 7 of 7 residents interview denied the allegation and reported that staff conducted assessment before admission. LPA and LPM reviewed R1's file and checked resident's assessment form dated 06/08/2022, individualized service plan dated 06/06/2022, and pre appraisal form dated 11/30/2022 which reveals R1 was assessed prior to admission to facility.

Allegation: Staff failed to seek medical attention for resident in a timely manner
It is being alleged that on two different occasions Resident fell and scraped Residents knees and toes and after the incidents Resident waited for an hour for the paramedics team. On 09/28/23 LPA and LPM interviewed staff # 1-6 (S1-S6), 6 of the 6 staff interviewed denied the allegation, during the interview 1 of 6 staff interviewed stated staff recall 2 separate incidents when R1 sustained a fall and facility staff informed R1 they could not provide the medical attention needed and called paramedics to assist. On 09/28/23 LPA and LPM interviewed residents #2-8 (R2-R8) 7 of 7 residents interview denied the allegation and reported staff will assist with medical needs when needed. On 09/28/23 LPA and LPM reviewed unusual incident reports dated 08/19/22, 11/23/22 and 11/28/22, incident reports revealed resident was provided with medical attention following incidents.

Allegation: Staff failed to administer resident's medication as prescribed
On 09/28/23 LPA and LPM interviewed staff # 1-6 (S1-S6), 6 of the 6 staff interviewed denied the allegation and reported that certified med techs are following Physicians orders. On 09/28/23 LPA and LPM interviewed residents #2-8 (R2-R8) 6 of 7 residents interview denied the allegation and reported medications are being administered correctly, 1 of 7 residents interviewed indicated that some med techs will not administer medications if a resident is late to med pass. On 09/28/23 at 2:30pm LPA and LPM conducted medication review of 7 residents. LPA did not observe any deficiencies.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20221214153652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 09/28/2023

NARRATIVE

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Allegation: Staff failed to provide appropriate transportation for resident
On 09/28/23 LPA and LPM interviewed S1-S6, 5 of 6 staff interviewed denied the allegation, 1 of 6 staff interviewed stated not being sure if the facility provides transportation or not. On 09/28/23 LPA and LPM interviewed R2-R8, 7 of 7 residents interviewed denied the allegation and stated residents obtain transportation as needed. On 09/28/23 LPA and LPM reviewed R1's admission agreement which indicates facility will "plan, arrange and/or provide for transportation to medical and dental local appointments."

Allegation: Staff refused to assist resident while in care
On 09/28/23 LPA and LPM interviewed S1-S6, 6 of 6 staff interviewed denied the allegation. On 09/28/23 LPA and LPM interviewed R2-R8, 7 of 7 resident's interviewed denied the allegation. 7 of 7 residents interviewed stated staff do not refuse to assist them.

Allegation: Staff failed to assist resident with showers
On 09/28/23 LPA and LPM interviewed S1-S6, 6 of 6 staff interviewed denied the allegation. 6 of 6 staff interviewed reported that residents shower 2-3xs a week deepening on their care plan. On 09/28/23 LPA and LPM interviewed R2-R8, 7 of 7 resident's interviewed denied the allegation or indicated not requiring assistance with hygiene needs. On 09/28/23 LPA and LPM reviewed R1's file, Pre appraisal dated 11/30/22 indicates R1 requires "help with bathing, hair care, and personal hygiene by staff." On 09/28/23 LPA and LPM reviewed unusual incident reports that indicate resident was provided with shower schedule and resident has been refusing assistance with showers. On 09/28/23 LPA and LPM reviewed refusal of shower notification dated 01/12/23 which indicates resident refused to shower on designated shower day.

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 is unsubstantiated.

Exit interview conducted to Assistant Administrator David Hernandez, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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