198204545-1-27-2023-11-AS-EMAZ-CPWRVN-20230314132148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204545
Report Date: 01/27/2023
Date Signed: 01/27/2023 03:56:17 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
01/19/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20230119162436

FACILITY NAME:	SIMLA VILLAS, REDONDO BEACH		FACILITY NUMBER:	198204545
ADMINISTRATOR:	SIMLA MEHTA		FACILITY TYPE:	740
ADDRESS:	2805 ROBINSON STREET		TELEPHONE:	(310) 483-6965
CITY:	REDONDO BEACH	STATE: CA	ZIP CODE:	90278
CAPACITY:	6	CENSUS: 4	DATE:	01/27/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	ADMINISTRATOR JENNIFER BOBADILLA		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not adequately supervise resident resulting in resident wandering from the facility on more than one occasion.
Facility staff did not reset door alarm to prevent residents from leaving without notification on more than one occasion.
Resident sustained a fracture while in care.
Facility staff are not adequately trained.

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 Simla Villas Redondo Beach facility on 01/27/2023 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 01/27/2023 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 01/23/2023 LPA Calderon interviewed W1 for complaint. On 01/27/2023 LPA Calderon requested copies of the following: Staff and Resident rosters, Needs and Service Plan, Physician Report, MAR, Dementia Training, and video for R1. On 01/27/2023 LPA Calderon reviewed medical records for R1. On 01/27/2023 LPA Calderon interview R2-R4 for complaint. On 01/27/2023 LPA Calderon interviewed S2-S3 for complaint. On 01/27/2023 LPA Calderon reviewed medical records for R1.

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: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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 5

Control Number 11-AS-20230119162436

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: SIMLA VILLAS, REDONDO BEACH	FACILITY NUMBER: 198204545
	VISIT DATE: 01/27/2023

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: Facility staff did not adequately supervise resident resulting in resident wandering from the facility on more than one occasion.

On 01/23/2023 LPA Calderon interviewed W1 for complaint. W1 states that resident has wandering behaviors and left the facility on 12/17/2022 and was found on Inglewood Blvd by unknown witness who called 911. W1 states that resident was transported to the hospital. W1 states that staff did not properly supervise resident and allowed resident to leave the facility. On 01/27/2023 LPA Calderon interviewed S1 who states she was advised by staff that resident had wandered and left the facility and was found on Inglewood Blvd. On 01/27/2023 LPA Calderon interviewed S2 who states that a guest was visiting the facility and left the front door unlocked. S2 states that staff was aware that resident had wandering behaviors and S2 could not find resident. S2 states that staff searched and 20 to 30 minutes later found resident on Inglewood Blvd, but 911 had been called and fire department took resident to the hospital. On 01/27/2023 LPA Calderon interviewed S3 who states that resident had wandering behavior and had left the facility. S3 states that S3 was told that a guest had left the front door unlocked when they left, and that resident followed the guest out the front door. On 01/27/2023 LPA Calderon reviewed resident facility paperwork to include physician report, needs and service plan and hospital records. Resident was noted to have wandering behavior by staff, but reports do not support this behavior. On 01/27/2023 LPA Calderon attempted to interview R1-R4 but due to communication issues residents were not able to answer any questions.

Regarding Allegation #2: Facility staff did not reset door alarm to prevent residents from leaving without notification on more than one occasion.

On 01/23/2023 LPA Calderon interviewed W1 for complaint. W1 states that on two separate occasions resident had left the facility and staff had not secured the front door by locking the door or making sure the door alarm was working. On 01/27/2023 LPA Calderon interviewed S1 who states that a unknow guest left the facility and staff did not lock or alarm the front door one time, but resident who has wandering behaviors left the facility. On 01/27/2023 LPA Calderon interviewed S2 who states that a unknown guest left the front door unlocked and staff did not follow up and make sure the front door was locked and alarmed. On 01/27/2023 LPA Calderon interviewed S3 who states that the responsibility to make sure the front door is locked is the guest. On 01/27/2023 LPA Calderon attempted to interview R1-R4 but due to communication issues residents are not able to answer any questions.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20230119162436

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: SIMLA VILLAS, REDONDO BEACH	FACILITY NUMBER: 198204545
	VISIT DATE: 01/27/2023

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 #3: Resident sustained a fracture while in care.

On 01/23/2023 LPA Calderon interviewed W1 for complaint. W1 states that resident has wandering behavior and had left the facility and was found on Inglewood Blvd by unknown witness who called 911. Resident was transported to the hospital and evaluated with a right fracture ankle due to a unwitnessed fall. On 01/27/2023 LPA Calderon interviewed S1 who states that resident was found on Inglewood Blvd, was transported to the hospital, and evaluated with a right ankle fracture. On 01/27/2023 LPA Calderon interviewed S2 who states that resident was found on Inglewood Blvd and was taken to the hospital with a right ankle fracture. On 01/27/2023 LPA Calderon reviewed hospital records for resident and resident was evaluated with a right ankle fracture.

Regarding Allegation #4: Facility staff are not adequately trained.

On 01/23/2023 LPA Calderon interviewed W1 for complaint. W1 states that resident had wandering behaviors and staff had not been trained to deal with a resident with this behavior and had no training as to how to secure the front door to prevent a resident from leaving. On 01/27/2023 LPA Calderon interviewed S1 who states that no formal training had been given for staff to deal with a resident with wandering behaviors. On 01/27/2023 LPA Calderon interviewed S2-S3 who state that they were aware of resident wandering behaviors but were not given formal training. On 01/27/2023 LPA Calderon reviewed dementia training given on 12/19/2022, only 2 staff of 10 signed the sign in sheet and not clear as to what training was given. No training could be found regarding securing the front door or use of alarm.

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 “facility staff did not adequately supervise resident resulting in resident wandering from the facility on more than one occasion” “facility staff did not reset the door alarm to prevent residents from leaving without notification on more than one occasion” “resident sustained a fracture while in care” “facility staff are not adequately trained” 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: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20230119162436

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: SIMLA VILLAS, REDONDO BEACH	FACILITY NUMBER: 198204545
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/03/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General: A Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will provide training to all staff regarding resident wandering behaviors. POC will be done by 2/3/23
	8 9 10 11 12 13 14	Based on interviews, observations and records the licensee failed to adequately supervise staff to prevent wandering behavior. This poses a potential health & safety risk to residents in care.	8 9 10 11 12 13 14
Type B 02/03/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General: A Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will provide training to all staff regarding securing /locking and alarming the front door to stop wandering behavior. POC will be done by 2/3/23
	8 9 10 11 12 13 14	Based on interviews, observations and records the licensee failed to adequately train staff regarding locking and alarming the front door. This poses a potential health & safety risk to residents in care.	8 9 10 11 12 13 14

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: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 11-AS-20230119162436

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: SIMLA VILLAS, REDONDO BEACH	FACILITY NUMBER: 198204545
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/03/2023 Section Cited CCR 87211(b)	1 2 3 4 5 6 7	87211 Reporting Requirements: B Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall provide training to alll staff regarding dementia and wandering behaviors to prevent serious injury. POC will be done by 2/3/23
	8 9 10 11 12 13 14	Based on interviews, observations and records the licensee failed to adequately supervise residents to prevent wandering behavior and serious injuries. This poses a potential health & safety risk to residents in care.	8 9 10 11 12 13 14
Type B 02/03/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General: A Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall provide training to alll staff regarding dementia care by POC date of 2/3/23
	8 9 10 11 12 13 14	Based on interviews, observations and records the licensee failed to adequately train staff to prevent wandering behavior and serious injuries. This poses a potential health & safety risk to residents in care.	8 9 10 11 12 13 14

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: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5