198205367-9-12-2024-11-AS-SCIS-DB33GA-20241115171401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205367
Report Date: 08/09/2024
Date Signed: 09/12/2024 05:59:00 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, 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
08/08/2023 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20230808165054

FACILITY NAME:	WESTCHESTER VILLA		FACILITY NUMBER:	198205367
ADMINISTRATOR:	EVANGELINE AGATEP		FACILITY TYPE:	740
ADDRESS:	220 W. MANCHESTER BLVD.		TELEPHONE:	(310) 673-1093
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90301
CAPACITY:	174	CENSUS: 90	DATE:	08/09/2024
		UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	Matthew Chinichian and Tawny Gant.		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.

INVESTIGATION FINDINGS:

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"Please note that this amended Complaint Investigation Report LIC9099 dated 09/12/2024 will supersede the original LIC9099 dated 08/09/2024, to include the correct allegation."
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Friday, August 09, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Licensee Matthew Chinichian and Administrator Tawny Gant. LPA Bunker explained the purpose of today's visit.
The investigation consisted of the following: During the investigation Interviews were conducted with staff members 1-4 (S1-S4) and residents 2-9 (R2-R9). Staff Member 4 (S4) stated she was not employed at the time of the incident and had no knowledge of the allegation in question. R1 was unavailable for an interview. LPA Bunker asked pertinent questions relevant to the nature of the complaint. During visits on 08/11/2023 and 08/09/2024, we toured the entire facility, including all buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats or concerns. See LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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-20230808165054

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WESTCHESTER VILLA	FACILITY NUMBER: 198205367
	VISIT DATE: 08/09/2024

NARRATIVE

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Continued LIC9099-C page 2

No evidence of neglect or abuse was observed during these visits.

We reviewed the resident files, including the physician's report, medical records, admission agreement, identification and emergency information, medication records, medication administration records (MARs), medication logs, medical assessments, consent forms, hospital records, incident reports, appraisal & needs service plan. LPA Bunker requested copies of supporting documents.

Allegation: Resident sustained an unexplained injury while in care.
Interviews with staff members 1-3 (S1-S3) indicated that the resident did not sustain an unexplained injury while in care. S1-S3 stated that the resident does not receive one-on-one care. S1-S3 reported that on August 8, 2023, at approximately 6:30 A.M., after completing the resident's morning grooming routine, caregiver Karina Portillo (S2) assisted the resident in being seated on the bed. While retrieving the resident's clothing from the closet, S2 suddenly heard a loud noise coming from the bathroom. Upon further investigation, S2 discovered that the resident had gotten up independently and proceeded to the bathroom. R1 had accidentally fallen and was found attempting to get up from the bathroom floor. S2 immediately assisted the resident back to bed, where she noticed a cut on the resident’s left cheek, which was bleeding. S2 promptly called for assistance, and Med Tech Edwin Villanueva responded immediately. The Med Tech called 911 without delay, and the resident was transported to Cedar Sinai-Marina Del Rey Hospital. The resident’s responsible party, family, and physician were notified. S1-S3 stated that S2 could not have prevented R1 from falling.

S1-S3 stated that staff are adhering to the resident's discharge instructions, monitoring the resident's condition closely, and keeping the family informed of the resident's progress. S1-S3 stated that the resident was not hit, and no staff member witnessed any such incident. Interviews with Residents 2-9 (R2-R9) revealed that they did not witness the resident falling or any instance of a resident being hit. R2-R9 expressed that they feel safe, are happy with the care and supervision provided, and believe that the staff are doing an excellent job.

S1-S4 emphasized that this is a 24-hour care facility, operating 7 days a week, 365 days a year, ensuring the safety of residents at all times. See continued LIC9099-C page 3

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230808165054

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WESTCHESTER VILLA	FACILITY NUMBER: 198205367
	VISIT DATE: 08/09/2024

NARRATIVE

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Continued LIC9099-C page 3

Investigation revealed the following: Staff members 1-3 (S1-S3) stated that the resident experienced an accidental fall on the morning of August 8, 2023. Emergency 911 services were immediately contacted, and the resident was transported to Cedars-Sinai Marina Del Rey Hospital. According to S1-S3, the fall was unavoidable, and no staff members or residents witnessed the incident or observed any physical altercation involving the resident at the facility.

The Inglewood Police Department responded to a call from Westchester Villa and concluded that no crime had occurred, resulting in no police report being filed. Medical records from the resident's physician and Cedars-Sinai Marina Del Rey Hospital confirmed a diagnosis of dementia, indicating that the resident is unable to manage their treatment, medication, or equipment. The resident also suffers from significant cognitive impairments, including difficulties with thinking, remembering, reasoning, judgment, and decision-making, which interfere with their ability to perform daily living activities or engage in social or occupational activities.

Staff members S1-S4 emphasized that Westchester Villa operates on a 24/7 basis, ensuring that residents are never left unattended. Residents R2-R9 confirmed that staff members are consistently available to assist and expressed satisfaction with their living conditions at the facility. S1-S4 and R1-R9 stated that the accommodations provided are comfortable and that the staff is dedicated to ensuring the safety and well-being of all residents. S1-S3 and R2-R9 denied any occurrence of a fight.

Investigator Juan Lozano of the Investigations Branch (IB) completed his investigation Care Report and determined that the findings were unsubstantiated.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Administrator Tawny Gant. There were no deficiencies cited. An exit interview was conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC9099 (FAS) - (06/04)

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