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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204972
Report Date: 11/02/2023
Date Signed: 11/02/2023 12:59:35 PM

Substantiated


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
10/25/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20231025084932
FACILITY NAME:ROSECRANS VILLA RESIDENTIAL CAREFACILITY NUMBER:
198204972
ADMINISTRATOR:SANDRA LOPEZFACILITY TYPE:
740
ADDRESS:14110 CORDARY AVENUETELEPHONE:
(310) 675-9163
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:135CENSUS: 110DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Sandra Lopez/AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff does not ensure facility is free of pests.
INVESTIGATION FINDINGS:
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On 11/02/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Sandra Lopez/Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator(A#1), Staff (S#1-S#10) residents (R#1-R#10), Reporting Party (RP) and Witness #1(W#1). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#10) Identification and Emergency Information, (R#1-R#10) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#10) Needs and Services Plan, (R#1-R#10) Medication Administration Record (MAR) for October 2023, LTCOP Report dated on 10/24/2023 and Copies of 5 months receipts from Pest Control company and Physical tour of the facility (10 random resident’s rooms, kitchen and common areas).

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
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 7
Control Number 11-AS-20231025084932
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: 11/02/2023
NARRATIVE
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Investigation Revealed the Following:

Allegation(s): Staff does not ensure facility is free of pests.

The details of the complaint alleged that the staff does not ensure the facility is free of pests.



During the records review, LPA Iniguez reviewed the following: LPA reviewed the report created by the LTCOP (Long-Term Care Ombudsman) investigator dated on 10/24/2023. It is written in the report that the investigator interviewed five random residents at different parts of the facility. 5 of the interviewed residents stated that they had seen insects roaming around the facility, mostly at nighttime. In addition, LPA reviewed the receipts from the pest control company from June-October 2023. LPA noticed that only ten rooms are fumigated at one time twice per month, and the kitchen is served once per month. Also, the LPA and administrator conducted a physical tour of the facility. During the tour, LPA inspected ten residents’ rooms, kitchen, dining room, and common areas; LPA did not observe the presence of pests inside the resident’s rooms, kitchen, and common areas.

During an Interview with the Administrator (A#1), she stated that the facility is clean and sanitary. Also, (A#1) stated that she has seen pests at the facility but not rodents. (A#1) stated that “we have caregivers that check the rooms daily and housekeepers that also clean the residents’ rooms and ensure there is no food inside the rooms. In addition, the maintenance person also sprays the room with over-the-counter bug spray”. In addition, (A#1) stated that the facility has a contract with a pest control company that comes twice a month to serve ten resident’s rooms and once per month to serve the common areas and the kitchen.

During interviews with residents (R#1-R#10), 10 out of 10 stated that the facility is clean and sanitary, but they have seen pests—also, 10 out of 10 stated that they have not seen rodents at the facility.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20231025084932
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: 11/02/2023
NARRATIVE
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During Interviews with staff (S#1-S#10), 10 out of 10 stated that the facility is clean and sanitary, but they have seen pests.

During interviews with the Reporting Party (RP), they stated that on 10/18/2023, LTCOP (Long Term Care Ombudsman) investigator visited the facility and interviewed approximately five residents in different areas of the facility (patio, common areas, rooms). RP said almost everyone that the investigator interviewed agreed that they had seen insects/bugs in the facility. In addition, RP stated that when they reviewed the pest control receipts, they noticed a note from the technician that said crevasses on the walls in the kitchen and dining room need to be repaired or filled.

During an Interview with Witness #1 (W#1), they stated that they service/fumigate ten residents’ units and common areas twice a month and once a month in the kitchen. LPA asked (W#1) if they could come more than twice a month if needed. (W#1) stated that if there’s a need, they can even come every week to keep the insects under control.

During this investigation, LPA found sufficient evidence to support the above-mentioned allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.

An exit interview was conducted, and a copy of the Complaint Report was given to Sandra Lopez/Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20231025084932
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2023
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds
(1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement was not met as evidence by:
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Licensee will ensure the facility is free of insects. As POC, licensee will require pest company to come 3 times per month to spray residents rooms until pests in under control. Also licensee will educate residents about having food in rooms. Licensee will sent proof of correction to LPA before POC due date.
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Based on interviews and records review, the licensee failed to ensure facility is free of insects.This poses a potential health and safety risk to all residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
10/25/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20231025084932

FACILITY NAME:ROSECRANS VILLA RESIDENTIAL CAREFACILITY NUMBER:
198204972
ADMINISTRATOR:SANDRA LOPEZFACILITY TYPE:
740
ADDRESS:14110 CORDARY AVENUETELEPHONE:
(310) 675-9163
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:135CENSUS: 110DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Sandra Lopez/AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Kitchen and dining room walls are in disrepair.
INVESTIGATION FINDINGS:
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On 11/02/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Sandra Lopez/Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator(A#1), Staff (S#1-S#10) residents (R#1-R#10), Reporting Party (RP) and Witness #1(W#1). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#10) Identification and Emergency Information, (R#1-R#10) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#10) Needs and Services Plan, (R#1-R#10) Medication Administration Record (MAR) for October 2023, LTCOP Report dated on 10/24/2023 and Copies of 5 months receipts from Pest Control company and Physical tour of the facility (10 random resident rooms, kitchen and common areas).

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20231025084932
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: 11/02/2023
NARRATIVE
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Investigation Revealed the Following:

Allegation(s): Kitchen and dining room walls are in disrepair.

The details of the complaint alleged that the kitchen and dining room walls are in disrepair...



During the physical tour of the facility, LPA and the administrator inspected the kitchen, dining room, and common areas. LPA did not observe cracks on the walls or other repairs that need to be done.

During the records review, LPA inspected the reports from the pest control company. The report dated 10/11/2023 stated that the “kitchen and dining room need crack and crevices sealed with caulking.” During the physical tour, LPA inspected these two areas but did not see cracks or crevices that must be repaired.

During an Interview with the Administrator (A#1), she stated that the facility is in good repair, and she has not seen cracks on the dining room and kitchen walls. Also, (A#1) stated that every time something needs repair, the staff is trained to report it immediately to the maintenance person or administrator.

During interviews with residents (R#1-R#10), 10 out of 10 stated that the facility is in good repair, and they have yet to see the wall of the dining room or kitchen that needs repair.

During interviews with staff (S#1-S#10), 10 out 10 stated that the facility is in good repair, and they have yet to see the walls of the dining room or kitchen with cracks or crevasses.

During interviews with the Reporting Party (RP), they stated that when they reviewed the pest control receipts, they noticed a note from the technician that said crevasses on the walls in the kitchen and dining room needed to be repaired or filled.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20231025084932
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: 11/02/2023
NARRATIVE
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During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

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.


California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of the Complaint Report was given to Sandra Lopez/Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7