198320092-8-23-2024-11-AS-RORN-D8SUY9-20240904155935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320092
Report Date: 08/21/2024
Date Signed: 08/23/2024 10:10:53 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, 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
08/23/2023 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20230823115112

FACILITY NAME:	LIFESTYLE BOARD AND CARE		FACILITY NUMBER:	198320092
ADMINISTRATOR:	ANGELES, JENNYLYN		FACILITY TYPE:	735
ADDRESS:	149 EAST 235TH STREET		TELEPHONE:	(562) 743-1037
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 6	DATE:	08/21/2024
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Kim E. Manor		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff unlawfully evicted a resident while in care
Staff did not properly report an incident to authorized representative
Staff behavior posed as a risk to a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, August 21, 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 Kim E. Manor. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: Interviews were conducted with Staff Member 1 (S1) and residents 2-6 (R2-R6). Resident 1 (R1) was unavailable for an interview and no longer resides at the facility. LPA Bunker asked questions relevant to the nature of the complaint. S1 stated none of their residents received an unlawful 30-day notice of eviction. S1 stated that the special incident reports were submitted to Community Care Licensing to all the appropriate agencies in a timely manner, prior to the filing of the complaint report. S1 also stated that the staff does not pose a risk to residents in care.

See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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 4

Control Number 11-AS-20230823115112

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: LIFESTYLE BOARD AND CARE	FACILITY NUMBER: 198320092
	VISIT DATE: 08/21/2024

NARRATIVE

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Continued LIC9099-C page 2

S1 Licensee Ms. Kim and LPA Bunker toured the facility both inside and outside, to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. During today's visit, no signs of neglect or abuse were observed. We observed and thoroughly reviewed the resident’s records.

LPA Pamela Bunker requested copies of the following documents: Personnel Report, Resident's Rosters, Admission Agreement, Identification and Emergency Information, Appraisal/Needs and Service Plan, Physician's Report, Medical and Dental Service Services records, Medication List, Medication log, Medication Administration Records (MARs), Functional Capability Assessment, Daily Progress Notes, House Rules, 30-day Eviction Notice, Unusual/Special Incident Reports, and Los Angeles Sheriff's Department Report.

Allegation #1: Staff Unlawfully Evicted a Resident While in Care
Staff 1 (S1), Licensee/Administrator Ms. Kim, reported that on 08/09/2023, a resident physically assaulted a staff member by punching them in the face. The Los Angeles County Sheriff's Department was called to the facility, and the resident was subsequently arrested. The following day, 08/10/2023, the resident voluntarily moved to a new location. S1 emphasized that the resident was not evicted but left of their own accord. S1 confirmed that all relevant documentation was faxed to LPA Ernand Dabuet, Community Care Licensing, and other appropriate agencies in a timely manner. S1 explained that on 08/10/2023, the resident's Case Manager contacted her to inform her that the resident would be voluntarily relocated to a new home. The Case Manager, along with the resident’s family, arranged to pick up the resident's personal belongings and medications. S1 assured that all documents related to this matter were submitted prior to the complaint being filed. S1 stated that at no point was the resident denied access to basic needs such as shelter, medication, food, etc. The resident was provided with their medications and personal belongings as required. S1 stated that the resident’s Case Manager indicated that the resident required a higher level of care and instructed her to draft a 30-day eviction notice for the resident’s Conservator. S1 stated that there was a misunderstanding and that she was acting under the Case Manager's instructions. S1 stated that the issue was resolved before this complaint was made, and the resident was permitted to return to the facility. S1 also stated that the resident’s Conservator later provided a letter indicating the resident's was moving. R2-R6 expressed satisfaction with the care provided by the staff and stated that no unlawful eviction notices were issued to any of them. Both Staff 1 (S1) and Residents 2-6 (R2-R6) denied the allegation of unlawful eviction.
See continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20230823115112

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: LIFESTYLE BOARD AND CARE	FACILITY NUMBER: 198320092
	VISIT DATE: 08/21/2024

NARRATIVE

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Continued LIC9099-C page 3

Allegation #2 Staff did not properly report an incident to authorized representative
Staff 1 (S1) Licensee Ms. Kim staff takes the matter of proper incident reporting with the utmost seriousness. S1 stated staff, has consistently adhered to the established protocols, as outlined in Title 22 Regulations. In the incident, which occurred on August 9, 2023, all relevant agencies, including the Los Angeles County Sheriff's Department and Community Care Licensing, were promptly notified following the incident.
On August 9, 2023, the resident in question was arrested and removed from the facility by the sheriff due to violent and inappropriate behavior. The required Special Incident Reports were duly filed with the appropriate agencies in a timely manner. LPA Bunker has verified that the incident reports were submitted in accordance with regulatory requirements. Staff 1, Ms. Kim, denies the allegation that the incident was not properly reported to the authorized representative.

Allegation #3 Staff behavior posed a risk to a resident while in care
Staff 1, Ms. Kim, stated that at no time did staff behavior pose a risk to any resident under their care. S1 stated it was the resident in question who presented a significant risk to both staff and residents. Despite repeated warnings not to use the stove to light cigarettes or smoke indoors—actions that compromised the safety of everyone in the facility—the resident continued this hazardous behavior. The resident's aggressive behavior and daily use of profane language toward staff, other residents, and neighbors further exacerbated the situation. Residents R2 through R6 stated that staff conduct has not posed any risk to them. R2-R6 expressed satisfaction with their living arrangements and accommodations, stating that they felt safe and secure in the facility.

S1 stated that on August 15, 2023, the resident was placed on a 51/50 hold due to a grave disability, as reported by the resident's Conservator and the hospital. This decision was based on the determination that the resident was a danger to themselves and others due to a mental disorder, leading to their detention in a psychiatric hospital. S1 stated she had never suggested that the resident could not return to the facility.

S1 stated that the facility maintains a zero-tolerance policy and is committed to providing a safe environment for all residents. S1 assured that the staff conducts themselves in a manner that upholds the highest standards of care.
See continued LIC9099-C page 4

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230823115112

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: LIFESTYLE BOARD AND CARE	FACILITY NUMBER: 198320092
	VISIT DATE: 08/21/2024

NARRATIVE

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Continued LIC9099-C page 4

Investigation revealed the following:
Staff S1 (S1) Ms. Kim stated that residents did not receive an unlawful eviction while in care. S1 explained that the resident’s Case Manager had indicated that the resident required a higher level of care and instructed her to draft a 30-day eviction notice for the resident’s Conservator. S1 stated that there was a misunderstanding and that she was acting under the Case Manager's instructions. S1 stated that the issue was resolved before this complaint was reported, and the resident was allowed to return to the facility. S1 stated that the resident 30-day eviction notice was reported to LPA Dabuet, LPM Hammond, Community Care Licensing, and the appropriate agencies in a timely manner. S1 stated staff, has consistently adhered to the established protocols, as outlined in Title 22 Regulations. S1 Licensee Kim stated the incident, which occurred on August 9, 2023, and all relevant agencies, including the Los Angeles County Sheriff's Department and Community Care Licensing, were immediately notified regarding the incident. On August 9, 2023, S1 stated all incident reports were properly reported to the authorized representative.
Staff 1, Ms. Kim, stated that at no time did staff behavior pose a risk to any resident under their care. S1 stated it was the resident in question who posed a significant risk to staff, other residents, and neighbors. S1 stated that the facility maintains a zero-tolerance policy and is committed to providing a safe environment for all residents. S1 assured that the staff conducts themselves in a manner that upholds the highest standards of care. S1 and R2-R6 stated staff does not pose a risk to residents while in care. S1 stated that their staff is a dedicated team that provides the necessary care and supervision to ensure the safety of all residents in care. S1 and R2-R6 denied the allegation.

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-Cs, was provided to the staff 1 (S1) Licensee Kim E. Manor.

There were no deficiencies cited.
Exit interview conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC9099 (FAS) - (06/04)

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