198204587-6-27-2023-28-AS-FFIS-CT9NUM-20230629104634

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204587
Report Date: 06/27/2023
Date Signed: 06/27/2023 02:46:33 PM

Unsubstantiated

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
03/23/2021 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210323093521

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: 12	DATE:	06/27/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	David Kim (Administrator)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.
Resident fell while in care and sustained a hip fracture.
Staff left resident in soiled diapers for an extended amount of time.
Residents call buttons are not being answered in a timely manner.
Staff yells at residents and do not treat residents with dignity and respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with David Kim (Administrator) and explained the purpose of the visit.

During the initial complaint investigation on 03/30/21, LPA conducted a health and safety check and requested a copy of the Staff and Resident roster. LPA toured the facility via Facetime video with David Kim and observed that the facility is clean and in good repair. There are nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Wash basins, showers/bathtubs and toilets are operable.

During today's visit, LPA obtained/reviewed a copy of the Staff schedule, Resident roster, Incident Report, Resident #1's records and Hospice patient incident report. LPA interviewed Staff #1 to #4 in the dining room and interviewed Residents #3 to #8 in their bedrooms.
Continue to LIC9099C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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-20210323093521

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: 06/27/2023

NARRATIVE

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In regards to the allegation: Resident sustained an unexplained injury while in care. Interviews with 3 of 3 Staff indicate they do not recall injuries sustained by Resident #2. Interviews with 6 of 6 Residents indicate Staff has never caused injury to Residents.

In regards to the allegation: Resident fell while in care and sustained a hip fracture. Based on record review, R#1 had a fall on 01/20/21 in the facility. Facility Staff notified the department and the Hospice agency. Review of Hospices records and text conversation indicate Hospice determined there were no signs and symptoms of a fracture. Hospice record did not indicate R#1 sustained a fracture. Interviews with 3 of 3 Staff indicate they were not aware of R#1 sustaining a fracture.

In regards to the allegation: Staff left resident in soiled diapers for an extended amount of time. Interviews with 3 of 3 Staff indicate Residents were not left in soiled diapers for an extended amount of time. Interviews with 6 of 6 Resident also indicate they were not left in soiled diapers for an extended amount of time.

In regards to the allegation: Residents call buttons are not being answered in a timely manner. Interviews with 3 of 3 Residents indicate call buttons are optional but none of the Residents are using a call button. Residents are consistently monitor throughout the day and night and provided timely service. Interviews with 6 of 6 Residents also indicate they do not use a call button. If assistance is need, Resident would use there phones to call Staff or verbally call out for assistance. Residents interviewed indicate assistance is provided in a timely manner.

In regards to the allegation: Staff yells at residents and do not treat residents with dignity and respect. Interviews with 4 of 4 Staff indicate they have never yelled at or treated Residents without dignity or respect and never witnessed other Staff yell at Residents or treated Residents without dignity or respect. Interviews with 6 of 6 Residents indicate Staff have never yelled at them or treated them without dignity or respect.

Based on LPA's record review and interviews, the investigation revealed: Although the allegations may have happened or is 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 and a copy of this report provided to David Kim (Administrator).

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC9099 (FAS) - (06/04)

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