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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204399
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:43:41 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
04/16/2024 and conducted by Evaluator Perry Scott
COMPLAINT CONTROL NUMBER: 11-AS-20240416103623
FACILITY NAME:VILLA REDONDO CARE HOMEFACILITY NUMBER:
198204399
ADMINISTRATOR:MARIA BRAVOFACILITY TYPE:
740
ADDRESS:237 REDONDO AVENUETELEPHONE:
(562) 434-9931
CITY:LONG BEACHSTATE: CAZIP CODE:
90803
CAPACITY:80CENSUS: 62DATE:
05/03/2024
UNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:David HernandezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not ensuring that resident is administered their medication(s) as prescribed.
Licensee is not ensuring that resident(s) have access to clean water while in care.
INVESTIGATION FINDINGS:
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On 04/18/24, at 09:00am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by David Hernandez, Assistant Administrator. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegations mentioned above.

The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R8) on 04/18/24. Resident Roster, Staff Roster, ID/Emergency Information, Physicians Report, Unusual Incident Report, & Needs and Service Plan for R1 and ID/Emergency Information for R2-R8 were obtained from the facility.

The investigation revealed the following: Allegation #1- Staff are not ensuring that resident is administered their medication(s) as prescribed.

Report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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-20240416103623
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: 05/03/2024
NARRATIVE
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The details of the complaint alleged that the facility was not ensuring that the resident is given assistance with insulin injections because the resident doesn’t have proper use of one of their hands. On 04/18/24, from 09:00am-12:00pm, LPA interviewed staff (S1-S5) and residents (R1-R8) regarding the allegation. 5 of 5 staff denied the allegation that the Staff are not ensuring that resident is administered their medication(s) as prescribed. All staff (S1-S5) stated that they are ensuring that the resident is administered all medication as prescribed. S1-S5 stated that R1 requires insulin injections and that R1 is fully capable of giving R1 injections but wants others to do it. Staff state that the facility has an LVN on shift for eight hours and doesn’t mind helping the resident with the injections but when the LVN is not on the schedule R1 needs to give R1 the injection because the caregivers or the Med-Techs are not trained to give insulin injections.

S1 explained to R1 that the caregivers and Med-Techs are only allowed to give hand over hand assistance and R1 must inject the medicine by R1’s self, the staff cannot plunge the needle into R1’s flesh. LPA reviewed the Physicians Report LIC 602, and it states the resident was trained and can administer their own injections. LPA also reviewed the Pre-Placement Appraisal Information LIC 603, and it informs the resident that they can only assist the resident with hand over hand injection assistance and the resident agreed to this prior to moving into the facility. LPA interviewed R1-R8 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff are not ensuring that resident is administered their medication(s) as prescribed. Most of the resident’s state that the facility staff advised them that the caregivers and Med-Techs are not allowed to plunge the needle into to them, only the LVN. Rather, they can assist with hand over hand assistance with injections of their insulin medication and that they have been trained to inject themselves by their primary care physician. They also state that the staff ensures that their medication is administered as prescribed.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not ensuring that resident is administered their medication(s) as prescribed. 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.

Report continued on LIC 9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240416103623
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: 05/03/2024
NARRATIVE
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Allegation: #2- Licensee is not ensuring that resident(s) have access to clean water while in care.

The details of the complaint alleged that the facility was not ensuring the resident has access to clean water. It was reported that a resident ingested water from the bathroom sink while attempting to cook a meal with the water and became ill. On 04/18/24, from 09:00am-12:00pm, LPA interviewed staff (S1-S5) and residents (R1-R8) regarding the allegation. 5 of 5 staff denied the allegation that Licensee is not ensuring that resident(s) have access to clean water while in care. All staff (S1-S5) stated that all residents have access to clean water. Staff stated that there is a filtered water dispenser on the second floor, bottled water available to all residents, and that all residents have access to the kitchen if water is needed. LPA interviewed R1-R8 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Licensee is not ensuring that resident(s) have access to clean water while in care. The residents state that they have not become ill from drinking water in the facility and that they have access to clean water, in that they can request bottled water or use the filtered water dispenser if needed.

Based on interviews, there is insufficient evidence to support the allegation that the Licensee is not ensuring that resident(s) have access to clean water while in care. 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.

No deficiencies were cited.

An exit interview was conducted with David Hernandez, Assistant Administrator, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3