198204587-9-21-2020-28-AS-MVAO-BTQN2Q-20200923100505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204587
Report Date: 09/18/2020
Date Signed: 09/21/2020 11:20:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2020 and conducted by Evaluator Christine Wong

COMPLAINT CONTROL NUMBER: 28-AS-20200518115851

FACILITY NAME:	VILLA, THE		FACILITY NUMBER:	198204587
ADMINISTRATOR:	DAVID KIM		FACILITY TYPE:	740
ADDRESS:	12565 DOWNEY AVENUE		TELEPHONE:	(562) 861-6694
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	15	CENSUS: 13	DATE:	09/18/2020
		UNANNOUNCED	TIME BEGAN:	02:52 PM
MET WITH:	Administrator - David Kim		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained an unexplained fracture while in care.
Staff do not ensure that residents are adequately fed.
Staff yell at residents.
Staff do not treat residents with dignity or respect.
Staff do not maintain a comfortable temperature in the home.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong initiated a subsequent complaint investigation to deliver findings on the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with administrator David Kim.

The investigation consisted of the following: On 05/28/2020, an initial 10 day complaint visit was conducted by LPA Juan Miramontes and documents were obtained which includes: residents facility and hospice care roster, Personal Roster (LIC500), Resident#1(R1’s) Identification and Emergency Information, Physician Report, Medication Administration Record (MARs) and Incident Report dated on 06/25/2020. The complaint was accepted by the CCL IB investigation Unit as a full investigation and assigned to IB Investigator Lorraine Patterson.

***See LIC 9099C for continuation of report ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2020

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 28-AS-20200518115851

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA, THE	FACILITY NUMBER: 198204587
	VISIT DATE: 09/18/2020

NARRATIVE

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IB investigator Lorraine conducted the investigation which includes interviews with the Resident#1- #3 (R1-R3), Licensee, R1’s family member, Hospice Care Bathing Nurse, caregiver (S1) and Hospice Care Case Manager. Investigator Lorraine also obtained Hospice Care’s hospice records and radiology report. On 09/16/2020, LPA Wong also interviewed additional two residents (R4-R5).

The investigation revealed of the following: Allegation#1: “Resident sustained an unexplained fracture while in care.” Per IB Investigator Lorraine, she interviewed with RP, facility staff and hospice care nurses and revealed R1 is 100 years old and has history of dementia, weakness and requires maximum assistance with all ADLs, including bed transfers. RP reported because administrator and S1 reduced facility staff’s hours, staff may accidentally cause R1’s injury themselves because staff are always in a rush and work tirelessly and may not realize they injured R1. Both administrator and S1 denied the allegation. Administrator stated R1’s unexplained injury likely resulted from of a bed transfer because of her age and being bedridden. Regarding R1’s radiology report which confirmed a left clavicle fracture, 6 cm, non-displaced. Osteoporosis was present. Radiology impressions further summarized normal for age, no obvious swelling. In addition, there’s no direct witness to the cause of the injury. Therefore, based on no direct witnesses, documentation, or evidence to support neglect or physical abuse resulted in R1’s unexplained injury, so the allegation is found UNSUBSTANTIATED.

Allegation#2: “Staff do not ensure that residents are adequately fed.” Based on the interviews with residents and all reported the facility provide real good food and the food is adequate for them. Administrator reported they provide three basic meals and snacks in between the day. And all the meals are nutritious and depends on resident’s dietary needs or special diet. During the time of the interview, LPA Wong observed the lunch was served which included meat, vegetable and fruit bowl on the tray and the lunch looks nutritious and adequate. Therefore, there is insufficient evidence to support the allegation and LPA finds the allegation#2 to be UNSUBSTANTIATED.

Allegation#3: “Staff yell at residents.” Based on the interviews with residents and all indicated the allegation has never happened and all the staff are great and excellent to the residents. Administrator reported he also works as caregiver, so he works with other caregivers’ side by side either day shift or night shift and never seen any caregivers amplified, harassed or threatened the residents. Therefore, there is insufficient evidence to support the allegation and LPA finds the allegation#3 to be UNSUBSTANTIATED.

***See LIC 9099C for continuation of the report***

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2020

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200518115851

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA, THE	FACILITY NUMBER: 198204587
	VISIT DATE: 09/18/2020

NARRATIVE

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Allegation#4: “Staff do not treat residents with dignity or respect.” Based on the interviews with residents and they all denied the allegation and reported all the staff treat residents very well and they are always respectful and dignified. Administrator reported all the staff received personal right training and no resident ever complained any staff treated them without dignity or respect. Therefore, there is insufficient evidence to support the allegation and LPA finds allegation#4 to be UNSUBSTANTIATED.

Allegation#5: “Staff do not maintain a comfortable temperature in the home.” Based on the interviews with residents and they all reported the temperature in the facility is comfortable which is not too hot or too cold. The air conditioning and heater are on which depends on the weather. According to the administrator, they try to make the facility temperature as comfortable as they can. They usually adjust the thermostat to 78 degree but not all residents are pleased because each resident has different needs. Per IB Investigator Lorraine stated the temperature of the facility was slightly warmer than cool in certain areas of the home, but uncertain if the extreme heat had any bearing on cooling the house because the air was not less than cool throughout. Therefore, there is insufficient evidence to support the allegation and LPA finds the allegation#5 to be UNSUBSTANTIATED.

Although the allegations 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 allegations are UNSUBSTANTIATED

A telephonic exit interview was conducted with Administrator David Kim. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2020

LIC9099 (FAS) - (06/04)

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