198204972-6-21-2023-11-AS-MVAO-CXLS8U-20231115123942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204972
Report Date: 06/21/2023
Date Signed: 06/21/2023 03:37:13 PM

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
06/12/2023 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20230612172910

FACILITY NAME:	ROSECRANS VILLA RESIDENTIAL CARE		FACILITY NUMBER:	198204972
ADMINISTRATOR:	SANDRA LOPEZ		FACILITY TYPE:	740
ADDRESS:	14110 CORDARY AVENUE		TELEPHONE:	(310) 675-9163
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	135	CENSUS: 112	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Sandra Lopez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff did not seek medical attention for resident in a timely manner.

Staff does not provide a safe and comfortable environment for resident.

INVESTIGATION FINDINGS:

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On 06/21/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a 10-day complaint visit at the facility listed above. LPA Gibbs met with Administrator, Sandra Lopez, and explained the purpose of today's visit.

During today's visit, LPA toured the physical Plant. LPA interviewed Administrator (S1), Staff (S2-S6), and Residents (R1-R9). LPA received and reviewed documents including staff roster, resident roster, Appraisal/Needs and Services plan for Residents (R1-R6), Physicians Report for Residents (R1-R6), Admission Agreement for Residents (R1-R6), Shift Report from 06/01/23-06/21/23, and In-Service Training conducted in 2023.

LPA's investigation revealed the following:

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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 11-AS-20230612172910

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: ROSECRANS VILLA RESIDENTIAL CARE	FACILITY NUMBER: 198204972
	VISIT DATE: 06/21/2023

NARRATIVE

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Allegation: Facility staff did not seek medical attention for resident in a timely manner
It is alleged, residents are not receicing medical care in a timely manner. During record review, LPA observed the house Physician and Psychiatrist visit the facility monthly. LPA reviewed Daily Staff Notes where staff indicate services provided, incidents that occurred and/or requests from residents to see a medical professional. During interviews with Staff (S1-S6), six out of six staff stated if a resident requests to see a medical provider the Administrator and LVN are informed. Depending on who they want to see the Administrator calls to makes an appointment as soon as possible or House Physician is informed, and/or staff offer to call to have resident transported to Emergency Room if they want to be seen immediately. During interviews Staff (S1-S6), six out of six stated if a change in condition is observed it is immediately brought to the attention of the LVN and/or Med Tech, who then call the Physician, and either call 911 for further evaluation or continue to monitor resident’s condition. Interviews with Residents (R1-R9), nine out of nine residents stated they see the physician regularly, and receive medical care in a timely manner or when requested. Based on interviews, record review, and observation LPA was unable to find evidence to support the above allegation.
Based on interviews conducted and records review, although the allegation 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 allegation is unsubstantiated.

Allegation: Staff does not provide a safe and comfortable environment for resident.
It is alleged, residents are violent, and resident does not feel safe. LPA reviewed Resident Admission Agreement, where is states staff monitor resident mental condition to ensure safety and well-being. Interviews with Staff (S2-S6), five out of five staff stated if a change in mental condition is observed they inform the LVN or Med Tech, who inform the Primary Care Physician (PCP). They then continue to monitor the resident, provide updates to the PCP, and if agitation or aggression increase the PCP will recommend calling to have resident transported to the hospital for further evaluation. Interviews with Staff (S1-S6), six out of six staff stated, if a resident is being aggressive there is enough staff to remove other residents from the area to ensure their safety and staff to continue de-escalation prompting with aggressive resident.

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230612172910

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: ROSECRANS VILLA RESIDENTIAL CARE	FACILITY NUMBER: 198204972
	VISIT DATE: 06/21/2023

NARRATIVE

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Interviews with Residents (R1-R9), nine out of nine residents stated they feel safe in the facility and staff work to ensure their safety. When Residents (R1-R9) were asked if they ever felt threatened, seven out of nine Residents stated they have never felt threatened. R1 stated they felt threatened when they first moved in, they would hear people walking up and down the hallways at night, and they weren’t used to that. R5 stated they felt threatened while outside smoking because everyone wants their cigarettes. Based on interviews, record review, and observation LPA was unable to find evidence to support the above allegation.

Based on interviews conducted and records review, although the allegation 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 allegation is unsubstantiated.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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