198204651-12-12-2022-11-AS-UCOL-CM4UJE-20221214143724

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204651
Report Date: 12/10/2022
Date Signed: 12/12/2022 10:20:19 AM

Unsubstantiated

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
01/04/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220104105921

FACILITY NAME:	HEARTS OF PARADISE HOME		FACILITY NUMBER:	198204651
ADMINISTRATOR:	BESSIE L COELLO		FACILITY TYPE:	740
ADDRESS:	4139 W. 177TH ST.		TELEPHONE:	(310) 371-7950
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 4	DATE:	12/10/2022
		UNANNOUNCED	TIME BEGAN:	02:14 PM
MET WITH:	Bessie Coello		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility did not follow resident's care plan.
Staff denied visitation to resident's responsible person.
Resident's responsible person was denied access to resident's records.

INVESTIGATION FINDINGS:

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On 12/10/22Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Bessie Coello. The purpose of the visit was to deliver findings on some of the allegations.

On 01/13/2022 Licensing Program Analyst (LPA) Don Senaha conducted an unannounced complaint investigation for the allegations listed above. The purpose of this visit was to request service documents and interview staff and residents. LPA requested service documents. LPA interviewed residents (R1-R5) and staff (S1-S3). A plant inspection of the facility was conducted. A plant inspection of the facility was conducted.

Evaluation Report continues LIC9099-C

This report serves as an amendment to clarify allegations in lines 4-8. It does not supersedes the complaint investigation findings reflected on report created on 12/10/22.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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-20220104105921

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: HEARTS OF PARADISE HOME	FACILITY NUMBER: 198204651
	VISIT DATE: 12/10/2022

NARRATIVE

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Investigation revealed:

Allegation: Facility did not follow resident’s care plan.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation. LPA obtained and reviewed hospice care plan for (R1). Care plan for resident (R1) included the teaching of hospice philosophy and purpose to the family through verbalized understanding. Care plan for resident (R1) included teaching caregivers through verbalized understanding positioning, disease process, medication (schedule, side effects, dose, frequency) and hospice on call system. Staff (S1-S3) stated staff does body check and changes the residents every day. Staff (S1) stated staff repositions the residents as necessary according to the care plan. LPA interviewed witness (W3) from hospice agency. Witness (W3) stated there were no concerns during the duration for resident (R1) residing at the facility with staff not following resident’s care plan.

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation.

Allegation: Staff denied visitation to resident’s responsible person.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation. LPA conducted interviews with residents (R2-R6). The majority of the residents verified there are no concerns with staff denying visitation. Staff (S1-S3) stated staff has no issues with visitation. LPA observed and reviewed sign in visitor logs and verified no concerns with visitations for responsible party of resident (R1).

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to s
support the allegation.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20220104105921

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: HEARTS OF PARADISE HOME	FACILITY NUMBER: 198204651
	VISIT DATE: 12/10/2022

NARRATIVE

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Allegation: Resident’s responsible person was denied access to resident’s records.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation. LPA obtained and reviewed the “Durable Power of Attorney” and the “Advance Health Care Directive” for resident (R1). LPA verified the Power of Attorney named is witness (W1). Staff (S1) verified witness (W2) is not the Power of Attorney and will only release resident’s records to the named Power of Attorney.

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation

Based on LPA’s interviews conducted, observation and records reviews, the preponderance of evidence standard has not been met. 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.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022

LIC9099 (FAS) - (06/04)

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