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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320044
Report Date: 06/01/2024
Date Signed: 06/05/2024 12:02:11 PM

Substantiated


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
02/22/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230222170857
FACILITY NAME:ALTERNATIVE RESIDENTIAL CAREFACILITY NUMBER:
198320044
ADMINISTRATOR:MCNAMARA, MINDYFACILITY TYPE:
740
ADDRESS:2653 W 225TH STREETTELEPHONE:
(310) 325-1735
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:6CENSUS: 5DATE:
06/01/2024
UNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Jemimah MejiaTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Staff left a resident soiled for extended period of time while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Assistant Administrator (A2: Jemimah Mejia). LPA conducted a risk assessment prior to entering facility. A2 informed LPA that the facility has no COVID cases nor do residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation.

An initial 10-Day visit was conducted by LPA Jeremiah Randle on 02/24/23 who was met by Assistant Administrator (A2: Jemimah Mejia); as Administrator (A1: Mindy McNamara) was unavailable. During this visit, LPA did not conduct interviews at the time. LPA toured the facility’s physical plant for health and safety purposes of residents in care. LPA observed one (1) resident currently sitting in the living room except for three (3) residents that were resting in bed and one (1) resident was in the hospital.
(Evaluation Report continues LIC 90099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2024
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 7
Control Number 11-AS-20230222170857
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: ALTERNATIVE RESIDENTIAL CARE
FACILITY NUMBER: 198320044
VISIT DATE: 06/01/2024
NARRATIVE
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Residents did not show signs of distress or abuse. LPA obtained copies of the following documents: Identification and Emergency Information (dated 02/18/23), Admission Agreements (dated 02/18/23), Physician’s Report (dated 02/17/23), Resident Appraisal (dated 02/18/23), Personal Rights (dated 02/18/23), Kaiser Permanente Hospital – Baldwin Park Medical Center medical records (dated 02/16/23 – 02/20/23), Torrance Memorial Hospice records (02/20/23 – 02/22/23), Staff Work Schedule & Roster (dated 08/23/22), Residents’ Roster (dated 01/25/23), and Hospice Notification (dated 02/20/23).

INVESTIGATION REVEALED THE FOLLOWING:

Regarding Allegation #2: This investigation revealed that Resident #1 was admitted to the facility on 02/20/23. Interviews conducted of hospice staff corroborated that the resident was not changed and that diaper was saturated in urine; and, it was reported to the resident’s family member. Witness #3 observed on 02/21/23 that Resident #1 was saturated in urine and had not received a diaper change since their last visit to the facility on 02/20/23. Witness #2 corroborated during their visit on 02/21/23, facility staff explained they had not changed Resident #1 because they were awaiting their hospital bed. Interview conducted of Administrator who admitted that facility staff only changed Resident #1 once - on the day that they were admitted to the facility. Administrator stated that the resident was difficult to turn because of their weight and size. Interviews conducted of facility staff (S1, S2) admitted that the resident had not been changed on 02/21/23 due to the resident requiring a two-person assist for bed bath and changing. Staff #1 stated that the resident received a change at night; but, Resident #1 had not been drinking fluids; therefore, the resident did not require frequent changes. (A review of the “Physician’s Report” documented under “Capacity for Self-Care: resident was not able to care for own toileting needs”. A review of the “Resident Appraisal” documented under “Services Needed: toileting assistance? Yes” and no record of an “Incontinent Schedule” form was observed for the resident.)

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff left a resident soiled for extended period of time while in care. ALLEGATION is found to be SUBSTANTIATED.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20230222170857
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: ALTERNATIVE RESIDENTIAL CARE
FACILITY NUMBER: 198320044
VISIT DATE: 06/01/2024
NARRATIVE
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation(s) issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the Administrator (Jemimah Mijia).

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20230222170857
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: ALTERNATIVE RESIDENTIAL CARE
FACILITY NUMBER: 198320044
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2024
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social
functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Licensee/Administrator agreed to comply and review Title 22 Regulation, Section “Observation of the Resident” and implement a plan detailing how Licensee/Administrator will ensure that they will ensure incontinent residents are regularly observed for changes. The plan of Correction (POC) is due to the CCLD/El Segundo ASC Regional Office by the POC due date on 06/15/24.
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This requirement is not met as evidenced by: Administrator admitted that Resident #1’s last incontinent change by facility staff was on 02/20/23 upon the resident’s admission to the facility. This violation poses a potential health and safety risk to residents in care.
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Email POC to: ernand.dabuet@dss.ca.gov
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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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2024
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 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
02/22/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230222170857

FACILITY NAME:ALTERNATIVE RESIDENTIAL CAREFACILITY NUMBER:
198320044
ADMINISTRATOR:MCNAMARA, MINDYFACILITY TYPE:
740
ADDRESS:2653 W 225TH STREETTELEPHONE:
(310) 325-1735
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:6CENSUS: 5DATE:
06/01/2024
UNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Jemimah MejiaTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Staff neglect resulted in a resident sustaining a pressure injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Assistant Administrator (A2: Jemimah Mejia). LPA conducted a risk assessment prior to entering facility. A2 informed LPA that the facility has no COVID cases nor do residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation(s).

An initial 10-Day visit was conducted by LPA Jeremiah Randle on 02/24/23 who was met by Asst. Administrator (A2: Jemimah Mejia); as Administrator (A1: Mindy McNamara) was unavailable. During this visit, LPA did not conduct interviews at the time. LPA toured the facility’s physical plant for health and safety purposes of residents in care. LPA observed one (1) resident currently sitting in the living room except for three (3) residents that were resting in bed and one (1) resident was in the hospital.
(Evaluation Report continues LIC 9099-)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2024
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-20230222170857
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: ALTERNATIVE RESIDENTIAL CARE
FACILITY NUMBER: 198320044
VISIT DATE: 06/01/2024
NARRATIVE
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Residents did not show signs of distress or abuse. LPA obtained copies of the following documents: Identification and Emergency Information (dated 02/18/23), Admission Agreements (dated 02/18/23), Physician’s Report (dated 02/17/23), Resident Appraisal (dated 02/18/23), Personal Rights (dated 02/18/23), Pomona Valley Hospital (PVH) medical records (02/13/23 – 02/16/23), Kaiser Permanente Hospital – Baldwin Park Medical Center medical records (dated 02/16/23 – 02/20/23), Torrance Memorial Hospice records (02/20/23 – 02/22/23), Staff Work Schedule & Roster (dated 08/23/22), Residents’ Roster (dated 01/25/23), facility’s Visitor Log (02/18/23 – 02/22/23), Hospice Notification (dated 02/20/23), POLST (dated 02/20/23), and Death Report (dated 02/22/23).

This complaint investigation was referred to California Department of Social Services (CDSS) Investigation Bureau (IB) and was assigned to Investigator Laarni Santiago. IB investigation included a review of Pomona Valley Hospital (PVH) medical records (02/13/23 – 02/16/23), Kaiser Permanente Hospital medical records (02/16/23 – 02/20/23), Torrance Memorial Hospice records (02/20/24 – 02/22/24), resident’s facility records, and death report. Interviews were conducted of Administrator, Staff #1, Staff #2, and Witness #1 – Witness #6. Former Resident #1 was not interviewed due to their passing on 02/22/23.

INVESTIGATION REVEALED THE FOLLOWING:

Regarding Allegation #1: This investigation revealed that Resident #1 was initially admitted to Pomona Valley Hospital on 02/13/23 and transferred to Kaiser Permanente Hospital on 02/16/23. Resident #1 was discharged from Kaiser Permanente Hospital on 02/20/24 (with physician’s orders for hospice care, effective 02/20/23) - the same day that the resident was admitted into the facility on 02/20/23. Interviews conducted of medical personnel (Witness #1, Witness #3 – Witness #6) observed Resident #1 revealed that the resident’s pressure injury on their sacral area “was already there” and acknowledged that it was not sustained at the facility. This was also corroborated by Witness #2 who observed the dressing on the resident’s pressure injury upon admission to the facility on 02/20/23. A review of medical records from Pomona Valley Hospital and Kaiser Permanente Hospital confirmed that Resident #1 already had a Stage II pressure injury on their sacrum area, which suggests the resident had already sustained prior to being admitted to the facility. A review of Resident #1’s physician’s report documented that the resident had a history of skin breakdown which was diagnosed Stage II pressure injury on the sacrum area.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20230222170857
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: ALTERNATIVE RESIDENTIAL CARE
FACILITY NUMBER: 198320044
VISIT DATE: 06/01/2024
NARRATIVE
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Based on the evidence gathered, interviews conducted, and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Staff neglect resulted in a resident sustaining a pressure injury is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the Assistant Administrator (Jemimah Mejia).

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7