198204972-11-4-2024-11-AS-RORN-DAXP4J-20241112095912

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204972
Report Date: 11/04/2024
Date Signed: 11/04/2024 04:45:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2024 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20240124143607

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:	11/04/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Sandra Lopez, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff caused injury to resident
Staff restrained resident

INVESTIGATION FINDINGS:

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On 11/4/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Sandra Lopez, Administrator, and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 1/25/24 LPA Felisa Shirley requested and received copies of the following records: Staff Roster, Resident Rosters, admissions agreement, identification and emergency information, physician’s report, MAR, Letters of Conservatorship, Preplacement Appraisal Information, Client personal property and valuables. On 11/4/2024 LPA Shirley conducted a health and safety check and requested and received copies of medical records from Kindred – Paramount, List of Hospitalizations, SIR dated 1/22/24, internal communications and body check dated 1/19/24. LPA interviewed staff S-1 – S-5 and clients C-2 – C-10.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

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-20240124143607

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ROSECRANS VILLA RESIDENTIAL CARE	FACILITY NUMBER: 198204972
	VISIT DATE: 11/04/2024

NARRATIVE

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Allegation: Staff caused injury to resident

On 11/4/2024 the department conducted a review of facility files. During file review, the department reviewed medical records from Kindred Hospital Paramount specifically the Patient Care Summary which shows that C-1 was hospitalized from 1/9/24 to 1/19/24. Further review of hospital records shows that C1 was noncompliant, removing monitors, leads and IV’s. During file review, the department observed facility body check documented on 1/19/24 which documents the bruises found on C-1 when client returned from the hospital. The department reviewed the facilities internal communication logs dated 1/19/24, which stated that C-1 came back from hospital at 3:30pm with bruises on both arms, both legs and across his chest. The department requested body checks prior to hospital admission date of 1/9/2024. On 11/4/2024 the department interviewed Administrator Sandra Lopez, who state that a body check is only performed upon observation of bruises, or an incident having occurred.
On 11/4/2024 the department interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked if staff caused injuries to residents? Of those interviewed, 5 out of 5 answered no. LPA interviewed Client-2 thru Client-10 (C-2 thru C-10). C-1 was not available to be interviewed. LPA asked clients if they have ever been injured by staff. Of those interviewed, 9 out of 10 answered no. Based on the information collected, an inspection of the facility, observation, record reviews, and interviews conducted, the Department found no evidence to support the allegations in this complaint. “Staff caused injury to resident,” therefore the allegation is unsubstantiated.
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 allegations are Unsubstantiated.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240124143607

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ROSECRANS VILLA RESIDENTIAL CARE	FACILITY NUMBER: 198204972
	VISIT DATE: 11/04/2024

NARRATIVE

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Allegation: Staff restrained resident
On 11/4/2024 the department conducted a review of facility files. During file review, the department reviewed medical records from Kindred Hospital Paramount specifically the Patient Care Summary which shows that C-1 was hospitalized from 1/9/24 to 1/19/24. Further review of hospital records shows that C1 was noncompliant, removing monitors, leads and IV’s and in the section titled, “Activity intolerance,” on pages 4 and 8, hospital records show C-1 was restrained with B wrist restraints.
During file review, the department observed facility body check documented on 1/19/24 which documents the bruises found on C-1 when client returned from the hospital. The department reviewed the facilities internal communication logs dated 1/19/24, which stated that C-1 came back from hospital at 3:30pm with bruises on both arms, both legs and across his chest. The department requested body checks prior to hospital admission date of 1/9/2024. On 11/4/2024 the department interviewed Administrator Sandra Lopez, who state that a body check is only performed upon observation of bruises, or an incident having occurred.
LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, does staff restrain clients? Of those interviewed, 5 out of 5 answered no. LPA interviewed Client-2 thru Client-10 (C-2 thru C-10). C-1 was not available. LPA asked, have you ever been restrained by staff?” Of those interviewed, 9 out of 10 answered no. Based on the information collected, an inspection of the facility, observation, record reviews, and interviews conducted, the Department found no evidence to support the allegations in this complaint. “Staff restrained resident,” therefore the allegation is unsubstantiated.
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 allegations are Unsubstantiated.

An exit interview was conducted, and a copy of the LIC 9099 report was provided to Sandra Lopez, Administrator.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

LIC9099 (FAS) - (06/04)

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