198204972-4-22-2021-11-AS-AJKK-C2BVP3-20210422163603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204972
Report Date: 04/22/2021
Date Signed: 04/22/2021 02:32:38 PM

Unfounded

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 DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/15/2021 and conducted by Evaluator Lourdes Montoya

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210415155417

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: 108	DATE:	04/22/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sandra Lopez		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff are not providing adequate care and supervision

INVESTIGATION FINDINGS:

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On 4/22/2021 at 10:00 AM, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent visit to deliver an investigation finding. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s inspection was conducted telephonically via FaceTime with Sandra Lopez, the Administrator.

Investigation consisted of the following:

On 4/21/2021, LPA Montoya conducted a virtual visit at the facility, interviewed Staff #1, the Administrator and Resident #1, the victim. LPA requested a copy of the residents’ roster and Resident #1’s incident report dated 3/2/2021. LPA also interviewed Witness #1, the Director of Nursing of Saint Vincent Health Care and Witness #2, an Ombudsman.

REPORT CONTINUED IN LIC 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

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-20210415155417

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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: ROSECRANS VILLA RESIDENTIAL CARE	FACILITY NUMBER: 198204972
	VISIT DATE: 04/22/2021

NARRATIVE

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Investigation Revealed the following:

Allegation: Staff are not providing adequate care and supervision

Based on LPA’s interviews, Resident #1 denied he filed a complaint against the above facility. Resident #1 stated he is temporarily residing in a Skilled Nursing Facility (NSF) for treatment. Resident #1 stated he has minor concerns that SNF staff are not providing adequate assistance in his daily activities. Staff #1 stated Resident #1 was admitted to Saint Vincent Health Center after he was discharged from Silverlake Medical Center and he has not returned to Rosecrans Villa Assisted Living facility yet. Interview with Witness #1 revealed Resident #1 was admitted to Saint Vincent Health Center on 3/3/2021 and scheduled to be discharged on 4/22/2021. Based on LPA’s review of the residents’ roster, Resident #1’s bedroom is located on the first floor #126. During LPA’s tour of the facility, LPA did not observe Resident #1 in his bedroom. Staff #1 stated in an interview that Resident #1 remains listed in the residents’ roster because he will be returning to the facility and his bedroom is reserved for his return. Based on LPA’s observation, interviews and record review, there was no evidence that facility staff are not providing adequate care and supervision.

Based on available evidence, interviews, and information obtained, LPA Montoya has concluded that the above allegation is UNFOUNDED.LPA confirmed that Resident #1 was temporarily admitted to a SNF for treatment where he is not receiving adequate assistance from staff in his daily activities. Resident #1 denied that Rosecrans Villa was not providing adequate care and supervision while residing at this facility.

No deficiencies cited under California Code of Regulations Title 22.

Exit Interview conducted, and a copy of the report was emailed to the Administrator, Sandra Lopez. LPA instructed Lopez to email back the signed copy to Lourdes.montoya@dss.ca.gov.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC9099 (FAS) - (06/04)

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