198320063-5-8-2024-11-AS-JHAD-D5CQ9W-20240517115858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320063
Report Date: 08/29/2022
Date Signed: 05/08/2024 09:59:09 AM

Unsubstantiated

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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20220823131651

FACILITY NAME:	AMOR VIDA CARE		FACILITY NUMBER:	198320063
ADMINISTRATOR:	MCNAMARA, MINDY		FACILITY TYPE:	740
ADDRESS:	2049 W 235TH STREET		TELEPHONE:	(310) 530-7104
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 5	DATE:	08/29/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jemimah Mejia		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff are not monitoring changes in resident's condition.
Facility staff are not maintaining proper records for residents.
Facility staff are asleep on the job at the facility.
Facility staff are not responding to residents' requests for help.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendy Gibbs made an unannounced visit to the facility and was greeted by Assistant Administrator Jemimah Mejia. LPA conducted a risk assessment prior to entering the facility. A1 informed (LPA) Gibbs that the facility has no COVID cases nor do the residents or staff have symptoms. The purpose for today’s visit is to investigate and deliver the findings pertaining to the above-mentioned allegations.
The investigation consisted of the following: An initial 10-Day visit was conducted by (LPA) Lourdes Montoya on 08/29/22 who met with Administrator McNamara. Addition, telephone investigation conducted by (LPA) Ernand Dabuet on 04/30/24. During the visit on 08/29/22, (LPA) Montoya requested copies of files for resident #1 (R1’s) ID and Emergency Information (dated: 07/13/22) Admissions Agreement LIC 604, (dated: 07/13/22), Physicians Report LIC 602A (dated: 07/12/22), Preplacement Appraisal Information LIC 603 (dated: 07/12/22), Appraisal/Needs and Services Plan LIC 625 (dated: 08/02/22), Daily Vital Signs Record (dated: 07/13/22 – 08/22/23), Progress Notes (dated: 08/03/22 – 08/23/23), Providence Little Company of Mary (dated: 06/12/22 – 07/13/22), Medication Training (dated: 06/15/22),

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

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-20220823131651

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
MONTEREY PARK, CA 91754

FACILITY NAME: AMOR VIDA CARE	FACILITY NUMBER: 198320063
	VISIT DATE: 08/29/2022

NARRATIVE

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Direct Care Orientation Checklist (dated: 12/01/19), Medication Administration Staff Training (dated: 12/01/19), Register of Facility Residents LIC 9020 (dated: 08/24//22 & 04/29/24) and Personnel Report LIC 500 (dated: 08/26/22).
INVESTIGATION REVEALED THE FOLLOWING:
Allegation #2: Facility staff are not monitoring changes in resident's condition.
The details of this complaint alleged that facility staff are not monitoring changes in resident’s condition. It was reported that facility did not provide a skilled nurse to monitor resident #1 (R1) for change in condition. Although, (R1) did not have any change in condition during (R1’s) stay at this facility, it was expected from the facility to provide a skilled nurse to monitor (R1). It was reported that (R1) had visits from a physical therapist to assist with a fracture ankle. A review of resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 07/13/22) and Admissions Agreement LIC 604 (dated: 07/13/22), revealed (R1) was admitted to Amor Vida Care on 07/13/23 and voluntarily terminated residency on 08/23/22. On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (3) out (3) staff #1-#3 (S1-S3) denied that facility staff are not following residents’ care plans. (S1-S3) revealed that the on-duty care staff check on (R1) in (R1’s) bedroom at least at least every two hours or as needed. On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (1) out (5) resident #2-#5 (R2-R5). (R2) revealed during the interview that staff checks (R2) blood pressure several times daily and that staff also monitors (R2's) sugar level, oxygen, Covid-19 screening, and temperature daily. (R2) reported that staff frequently checks on (R2). (R3-R5) were not available for an interview and unable to obtain statement from the three residents.
On 04/30/24, between 04:00 am – 5:00 pm, (LPA) Ernand Dabuet attempted to interview resident #3-#5 (R3-R5). A health condition limits (R3-R5’s) ability to carry a full conversation or make a full statement.
(LPAs) Montoya and Dabuet attempted to interview resident #1 (R1) on 08/29/22 and 04/30/24, who no longer resided at the facility. (R1) did not provide a forwarding contact information and unable to obtain a full statement. A review of (R1’s) facility progress notes (dated: 08/3/22 through 08/23/22) and Daily Vital Sign Record (dated: 07/13/22 through 08/22/22), (R1) was being monitored for change in condition.
Allegation #6: Facility staff are not maintaining proper records for residents.
It alleged that facility staff are not maintaining proper records for residents. It was communicated the facility does not maintain records for (R1).
On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya requested to obtained and review (R1) services records which included the following: Admission Agreement LIC 604 (dated: 07/13/22) Appraisal/Needs and Services Plan LIC 625 (dated: 08/02/22), Physician's Report LIC 602A (dated: 08/02/22), Identification and Emergency Information LIC 601 (dated: 07/13/22), Daily Vital Signs Chart (dated: 07/13/22 – 08/22/23), Progress Notes (dated: 08/03/22 – 08/23/23), Providence Little Company of Mary (dated: 06/12/22 – 07/13/22, and Medication Administration Records, Covid-19 test, Covid Vaccination records, and Covid-19 daily screening.
Allegation #7: Facility staff are asleep on the job at the facility.
It is alleged Facility staff are asleep on the job at the facility. It was reported that facility staff are not sleeping on the job,

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220823131651

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
MONTEREY PARK, CA 91754

FACILITY NAME: AMOR VIDA CARE	FACILITY NUMBER: 198320063
	VISIT DATE: 08/29/2022

NARRATIVE

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but rather they were laying down on the couch with their feet raised from the floor. It was described staff would rest in the living room approximately 10 am and uncertain on how much time staff is taking a rest.
On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (3) out (3) staff #1-#3 (S1-S3) denied this allegation. (S1) reported that staff take morning, afternoon, and lunch break. The staff would usually sit on the couch in the living while taking a break, but they do not sleep on the job. (S2-S3) indicated they do not sleep in the facility while on duty. (S2-S3) stated they just rest in the living on the couch while on break. On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (1) out (5) resident #2-#5 (R2-R5). (R2) communicated that staff do not sleep on the job and unable to verify this allegation. (R3-R5) were not available for an interview and unable to obtain statement from the three residents. On 04/30/24, between 04:00 am – 5:00 pm, (LPA) Ernand Dabuet attempted to interview resident #3-#5 (R3-R5). A health condition limits (R3-R5’s) ability to carry a full conversation or make a full statement. (LPAs) Montoya and Dabuet attempted to interview resident #1 (R1) on 08/29/22 and 04/30/24, who no longer resided at the facility. (R1) did not provide a forwarding contact information and unable to obtain a full statement.
Allegation #8: Facility staff are not responding to residents' requests for help.
It is alleged that facility staff are not responding to residents' requests for help. It was conveyed that facility staff did not respond to residents' requests for help. However, it was also reported that facility staff do help when requested.
On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (3) out (3) staff #1-#3 (S1-S3) revealed this accusation is inaccurate. (S1) communicated that (S1) informed (R1’s) family and private caregivers to request assistance from facility staff whenever it is needed. (S1) included that facility staff make rounds to check on residents every two hours or as needed. (S2-S3) reported staff are always ready to help with residents even during their break time. On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (1) out (5) resident #2-#5 (R2-R5). (R2) expressed that staff are always available and ready to help when asked. (R3-R5) were not available for an interview and unable to obtain statement from the three residents. On 04/30/24, between 04:00 am – 5:00 pm, (LPA) Ernand Dabuet attempted to interview resident #3-#5 (R3-R5). A health condition limits (R3-R5’s) ability to carry a full conversation or make a full statement. (LPAs) Montoya and Dabuet attempted to interview resident #1 (R1) on 08/29/22 and 04/30/24, who no longer resided at the facility. (R1) did not provide a forwarding contact information and unable to obtain a full statement.
Based on information gathered, LPA did not find sufficient evidence to support allegations " Facility staff are not monitoring changes in resident's condition", "Facility staff are not maintaining proper records for residents", "Facility staff are asleep on the job at the facility", Facility staff are not responding to residents' requests for help". Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.
An exit interview was conducted with Designee Jemimah Mejia, and a copy of the LIC 9099 report was provided.
This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created on 08/29/22.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

LIC9099 (FAS) - (06/04)

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