198204399-3-29-2024-11-AS-EMAZ-D46RH8-20240409130154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204399
Report Date: 03/29/2024
Date Signed: 03/29/2024 12:05:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2024 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20240325115658

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: 61	DATE:	03/29/2024
		UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Maria Bravo-Administrator		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

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Staff did not inform resident's authorized representative of a change in resident's condition.

INVESTIGATION FINDINGS:

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On 3/29/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Maria Bravo /Administrator and explained the purpose of this visit.

Investigation Consisted of: Interview with Administrator(A#1), Facility Staff (S#1-S#3), Residents (R#1-R#5) and Reporting Party (RP). LPA Iniguez reviewed the following records: Staff Roster, Residents Roster, (R#1-R#5) Physicians Report for Residential Care Facilities for the Elderly or LIC 602, (R#1-R#5) Admissions Agreement, (R#1-R#5) Identification and Emergency Information LIC 625, (R#1-R#5) Appraisal/Needs Service Plan LIC 625, (R#1-R#5) Medication Administration Record (MARS) for the month of March 2024, (R#1)’s Dath Report dated:1/2/24, (R#1)’ Basic fact Sheet, copy of (R#1)’s Unusual Incident Report dated: 12/26/2023 and a physical tour of the facility.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240325115658

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 03/29/2024

NARRATIVE

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Investigation Revealed the Following:

Allegation: Staff did not inform resident's authorized representative of a change in resident's condition.

The details of the complaint alleged that the facility staff did not inform the resident’s authorized representative when they went to the hospital.

During the records review, LPA Iniguez examined the facility face sheet of resident (R#1). It was noted that (R#1) did not list a contact person, nearest kin, or legal guardian, but rather listed themselves as their legal representative. Additionally, LPA observed the Identification and Emergency Information sheet was reviewed, and it was found that (R#1) did not list a legal guardian or conservator, but only their insurance company as the entity responsible for paying for their care while living at the facility. Moreover, LPA reviewed (R#1)'s Physicians Report for Residential Care Facilities for the Elderly (RCFE), or LIC 602A, where (R#1) again listed themselves as their legal representative. Lastly, a copy of an Unusual Incident Report-LIC 624 dated 12/26/23 was reviewed, which indicated that when (R#1) went to the hospital that day, the facility informed (R#1)'s physician and CCLD.

During an interview with the Administrator (A#1), she stated that the facility's sending residents to the hospital is based on a case-by-case basis; the residents will choose to go. If the resident decides to go to the hospital, the facility will inform the resident's physician and the responsible party if they have one. Once the resident returns from the hospital, we will assess the resident in case they need more care. Also, we submit an Unusual Incident Report to CCLD when a resident goes to the hospital. Also, (A#1) stated that (R#1) was self-responsible; they needed a representative listed on their identification and emergency information form and were not conserved. In addition, (A#1) stated that the facility has always notified residents' legal representatives and their physicians; we try to build a relationship with the residents' representative and their physicians.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240325115658

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 03/29/2024

NARRATIVE

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During an interview with staff (S#1-S#3), (3) out of (3) staff stated that the facility process when it comes to sending a resident to the hospital is: "We call 911, the resident is sent out we notify their physician and their responsible party. If the resident does not have a responsible party, we only notify their doctor and CCLD about the event in an Unusual Incident Report." Also, (3) out of (3) staff stated that when (R#1) went to the hospital on December 2023, they just informed their physician and CCLD since (R#1) was their legal representative. Additionally, (3) out of (3) staff stated that the facility has always communicated with the residents' legal representatives and physicians in case they go to the hospital.

During interviews with residents (R#2-R#6), (5) out of (6) residents stated that they feel the facility offers a safe environment for them and the other residents in care. Also, (5) out of (6) residents think the facility will contact their families, legal representatives, and doctors in case of an emergency. In addition, (3) out of (6) state that they have gone to the hospital before, and the facility informed their legal representatives and doctors.

During this investigation, LPA found did not find sufficient evidence to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

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, and a copy of the Complaint Report was given to Maria Bravo /Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

LIC9099 (FAS) - (06/04)

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