198204587-1-4-2023-28-AS-RORN-CMRRUZ-20230104122046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204587
Report Date: 12/29/2022
Date Signed: 01/04/2023 11:00:15 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/03/2020 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200803133247

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: 10	DATE:	12/29/2022
		UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:	David Kim		TIME COMPLETED:	12:09 PM

ALLEGATION(S):

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Insufficient staffing to meet the residents' needs.
Residents sustained pressure injuries while in care.
Staff are unable to manage residents' incontinence needs.

INVESTIGATION FINDINGS:

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**** This amended report supersedes report dated 12/29/2022. It was created to remove confidential information. Revision did not change any other aspects of the report and all aspects remain the same.****

Licensing Program Analyst (LPA) Alberto Lopez initiated a subsequent complaint visit to deliver findings on the allegations listed above. Previous visit was initiated telephonically on 08/04/2020 LPA Almaraz contacted Administrator and requested copies of staff and resident roster along with other pertinent documentation to be emailed to LPA. LPA Lopez made visit on 11/10/2022 and requested 2020 staff and resident’s rosters and asked Administrator for contact information (phone numbers of 2020 staff) and physician’s report for 2020 residents. On 12/20/2022 LPA made another visit to obtain medical/hospice records of several of the residents that resided at facility in 2020. LPA met with Administrator David Kim and discussed the purpose of today’s visit.

(continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

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-20200803133247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA, THE	FACILITY NUMBER: 198204587
	VISIT DATE: 12/29/2022

NARRATIVE

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Regarding Allegation: Insufficient staffing to meet the resident's needs. It is Alleged that that the facility only has four caregivers and that the owners themselves will work 24-hour shifts to cover. And because of this, the quality of care of the residents has slipped.

It is alleged that on a regular basis, caregivers would arrive for their shifts (after the owners have worked a 24-hour shifts) to find the residents briefs/diapers to be soiled and it is alleged that two of the residents have developed pressure injuries due to sitting in soiled diapers for too long. It is alleged that there are times when a resident calls for assistance but that it can take up to 30 minutes for a caregiver to respond to the alarm. The investigation reveals that in 2020 facility had 10 total staff, that included 7 caregivers and the LIC 500, time sheets, and schedule showed that shifts had coverage 24 hours a day, 7 days a week. LPA Interviewed current staff and 3/3 denied the allegations. 9/9 current residents could not collaborate the allegations. LPA Interviewed staff that was present during 2020 and no longer employed at facility. 3 of 4 former staff interviewed collaborated the allegations as did 1 of 2 witness.
No documented evidence was discovered regarding the allegation.
Therefore, the allegation is unsubstantiated

Regarding Allegation: Residents sustained pressure injuries while in care. It is alleged that residents sustained pressure sores while in care. LPA interviewed current residents and 9/9 did not collaborate the allegations and none had a pressure sore at the time of visit. 3/3 current staff denied the allegation. LPA interviewed former staff. 4/4 staff and 1/2 witness collaborated the allegation. Staff and one witness were able to identify former residents: FR10, FR15 and FR22 who were alleged to have developed pressure sores while in care. Review of the former resident’s FR22 file and documentation revealed that FR22 did not have pressure ulcer at the time of allegation and was under hospice care. Review of FR10 documentation revealed that FR10 arrived at facility under hospice care and with stage 4 pressure sore. Review of FR15 hospice records show that resident was admitted to hospice on 01/07/2019 and FR15 developed skin tear and wound while under hospice care.

No documented evidence was discovered regarding the allegation.

Therefore, the allegation is unsubstantiated

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20200803133247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA, THE	FACILITY NUMBER: 198204587
	VISIT DATE: 12/29/2022

NARRATIVE

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Regarding Allegation: Staff are unable to manage residents' incontinence needs. It is alleged that resident’s incontinence needs were not taken care of and may have developed pressure injuries due to sitting in soiled diapers for too long. 3/3 current staff denied the allegations. 9/9 current residents could not collaborate the allegations. 1 of 2 witness did not collaborate the allegations. 4/4 former staff collaborated the allegations, however review of documentation revealed that no residents developed pressure sore due to incontinent needs not being taken care of. Only 2 resident’s that were present during 2020 are still at facility. Former residents are all presumed to have passed away.

No documented evidence was discovered regarding the allegation.

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.

Exit interview conducted with Administrator David Kim and copy of report provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

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