198320063-5-8-2024-11-AS-JHAD-D5CQ9V-20240517115857

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320063
Report Date: 01/05/2024
Date Signed: 05/08/2024 09:45:02 AM

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
08/23/2022 and conducted by Evaluator Elvira Gonzalez

PUBLIC

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:	01/05/2024
		UNANNOUNCED	TIME BEGAN:	02:27 PM
MET WITH:	Jemimah Mejia		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Facility staff are not following residents' care plans.
Resident's diaper is always found wet and not being changed.
Facility staff are not properly trained.
Facility does not provide nutritious foods to residents.

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 conduct a subsequent visit 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 (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), Direct Care

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMOR VIDA CARE	FACILITY NUMBER: 198320063
	VISIT DATE: 01/05/2024

NARRATIVE

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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).

Investigations revealed the following:

Allegation #1: Facility staff are not following residents' care plans.

It was alleged that the facility staff are not following (R1’s) care plans.
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) who denied that facility staff are not following residents’ care plans. (S1-S3) revealed that staff followed (R1’s) plan of care which included bathing/showering, dressing, transition in and out of bed or wheelchair, walking, use of toilet or diaper change, eating and taking medications.
On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (1) out (5) resident #2-#5 (R2-R5). (R2) stated staff followed (R2’s) plan of care and the staff bathe (R2) three times weekly. (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) service records, (R1) had no history of skin breakdown and current medical assessment does not indicate any skin rashes or bed sores which supports that staff did not fail to follow (R1’s) care plan. (LPA) Montoya observed during the investigation that residents are provided with proper care by staff. Based on gathered information, there is no sufficient evidence to corroborate the allegation above.

Allegation #3: Resident's diaper is always found wet and not being changed.

It was alleged that (R1’s) diaper is always found wet and not being changed.
On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (3) out (3) staff #1-#3 (S1-S3) denied that (R1's) diaper was found wet and not being changed. (S1-S3) revealed (R1) is monitored by staff every two hours during the day and every two to three hours during the night or as required. (R1’s) diaper is changed when wet statements made by (S1-S3).

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMOR VIDA CARE	FACILITY NUMBER: 198320063
	VISIT DATE: 01/05/2024

NARRATIVE

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On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (1) out (5) resident #2-#5 (R2-R5). (R2) stated is not incontinent and does not need assistance with toileting. (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 a review of (R1’s) plan of care, changing diaper when wet was listed on the plan. (LPA) Montoya did not observe (R1) during the investigation as the resident was no longer residing at the facility. Based on gathered information, there is no sufficient evidence to corroborate the allegation above.

Allegation #4: Facility staff are not properly trained.

It was alleged that facility staff are not properly trained.
On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (3) out (3) staff #1-#3 (S1-S3) repudiated that staff are not properly trained. (S1-S3) revealed all staff are fully trained. Staff are properly trained in Assisted Daily Living (ADL) care including transferring residents from bed to wheelchair, proper toileting, and bathing communicated by (S1-S3).
On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (1) out (5) resident #2-#5 (R2-R5). (R2) declared this allegation is untrue and that staff are trained. (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 forwarding contact information and was unable to obtain a full statement.
A review staff training records revealed that staff are fully trained in Medication, Medication Administration, and Resident’s Direct Care. During the investigation, (LPA) Montoya did not observe improper care provided to residents by staff. Based on gathered information, there is no sufficient evidence to corroborate the allegation above

Continued on LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMOR VIDA CARE	FACILITY NUMBER: 198320063
	VISIT DATE: 01/05/2024

NARRATIVE

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Allegation #5: Facility staff does not provide nutritious foods to residents.
It was alleged that facility staff does not provide nutritious food to residents.
On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (3) out (3) staff #1-#3 (S1-S3) contested that the facility staff does not provide nutritious food to residents. (S1-S3) asserted the staff prepares healthy and nutritious food for the residents. (S1-S3) described the residents are served with a balanced diet which includes vegetables, meat, and fruits. Staff prepares a variety of cuisine. (S1-S3) reported there have been no complaints from residents about food. The facility provided a sample menu to guide staff in preparing nutritious food.
On 8/29/2022, between 09:00 am – 5:00 pm, (LPA) Montoya interviewed (1) out (5) resident #2-#5 (R2-R5). (R2) disagreed that the facility staff does not provide nutritious food to residents. (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 record review, the facility has a meal plan which includes a mixture of different vegetables, meat, seafood, fruits, and refreshments. (LPA) Montoya observed the facility has sufficient perishable and non-perishable food supplies during the visit on 08/29/22. Based on gathered information, there is no sufficient evidence to corroborate the allegation above.

Based on observation, records review and interviews conducted, LPA Montoya did not find sufficient evidence to support allegations “Facility staff are not following residents' care plans”, “Resident's diaper is always found wet and not being changed”, “Facility staff are not properly trained”, and “Facility does not provide nutritious foods to residents”. Although the allegations may have happened or are 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 with Jemimah Mejia and a copy of the 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 01/05/24.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

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