198320096-9-12-2023-11-AS-EMAZ-CXSUBC-20231121142606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320096
Report Date: 09/12/2023
Date Signed: 09/12/2023 12:22:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
09/08/2023 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20230908080341

FACILITY NAME:	BRICKSTONE MANOR		FACILITY NUMBER:	198320096
ADMINISTRATOR:	DADABHOY, MUQEET		FACILITY TYPE:	740
ADDRESS:	20551 MADISON ST.		TELEPHONE:	(310) 251-2382
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 6	DATE:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Muqeet Dadabhoy-Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff member yells at residents
Staff member did not administer resident's medication as prescribed

INVESTIGATION FINDINGS:

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On 9/12/2023 LPA Alfonso Iniguez conducted and unannounced complaint visit. LPA Iniguez meet with Muqeet Dadabhoy/Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted interviews with Residents (R#1-R#3), Administrator(A#1), Staff (S#1-S#3), Reporting Party (RP), Hospice Nurse (W#1) and Resident’s wife (W#2). LPA obtained and reviewed (R#1-R#3) Physicians Report, (R#1-R#3) Medication Administration Record (MAR) from April-September 2023, (R#1-R#3) Centrally Store Medication Destruction Record for September 2023, (R#1-R#3) Physical review of medications, (R#1-R#3) Needs and Services Plans, client roster and staff roster.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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-20230908080341

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BRICKSTONE MANOR	FACILITY NUMBER: 198320096
	VISIT DATE: 09/12/2023

NARRATIVE

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Investigation Revealed the Following:

Allegation: Staff member yells at residents.

The details of the complaint alleged that one of the facility staff yells at residents.

During the records review, LPA reviewed (R#1)'s physician's report for residential care facilities for the elderly (LIC 602A); his primary diagnosis is not dementia, same as (R#2) and (R#3). (R#1-R#3) were able to answer all the LPA's questions.

During an interview with the Administrator, he stated that he knows the residents' rights, and he and his staff review them daily. They just had an in-service six months. Also, he stated that he had never broken a resident's right before, and neither did the staff. In addition, the Administrator stated that he has never yelled or screamed at a resident and neither the staff.

During interviews with staff (S#1-S#3), 3 out of 3 stated that they know the personal rights of residents, and they recently took training regarding the personal rights of residents. Also, 3 out of 3 stated that they have never broken a resident's right and have never yelled or screamed at a resident before. In addition, 3 out of 3 stated that they had never heard or seen a staff yelling or screaming at a resident before.

During interviews with residents (R#1-R#3), 3 out of 3 stated that they are aware of their personal rights, and they feel the staff is trained when it comes to residents' personal rights. Also, 3 out of 3 stated that the staff has never broken their rights and 3 out of 3 stated that the staff never yelled at or screamed at them before; 3 out of 3 stated they feel safe getting care from the facility staff.

During an interview with the reporting party (RP), they stated that on 9/7/23, RP received a phone call from R#1's wife (W#1). They told RP that they spoke to one of the residents, and the resident told (W#1) that they don't like it when (S#1) yells at the residents.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20230908080341

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BRICKSTONE MANOR	FACILITY NUMBER: 198320096
	VISIT DATE: 09/12/2023

NARRATIVE

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During an interview with (W1), they stated that on 9/7/23, they were at the facility conducting a patient evaluation, and they witnessed an argument between (S#1) and another staff; both were arguing in front of the residents. (W#1) noticed residents were scared because of the argument between the staff.

During the Interview with (W2), they stated that on 9/7/23, they were at the facility, and one of the residents told them that they were upset because they heard (S#1) yelling at (R#2) and (R#3). The resident kept repeating themself. They told the resident they would help them talk to the Administrator regarding (S#1) 's behavior.

Allegation: Staff member did not administer resident's medication as prescribed.

The details of the complaint alleged that staff is not writing in the MAR when giving medications to residents.

During the records and medication review, LPA inspected (R#1-R#3) Medication Administration Records (MAR) from April to September 2023, physical medications, and the Centrally Store Medication and Destruction Records; LPA did not find any discrepancies; also, LPA did not find expired medications. LPA noticed the staff is writing down in the MAR the prescription given to (R#1-R#3).

During an interview with Administrator (A#1), he stated that the facility follows the MAR (Medication Administration Records) and the Centrally Store Medication Destruction Record. Staff reviews both systems daily to ensure they follow the doctor’s instructions. In addition, the administrator stated that the residents are getting their medications as prescribed by their physician, and he mentioned that the facility staff tries to document in the MAR consistently, but in case of a possibility of missing a medication given, they will correct it right away.

During interviews with staff (S#1-S#3), 3 out 3 stated that the facility uses the Medication Administration Records (MAR) daily, and they believe the residents are getting their medications as prescribed by their physician. In addition, 3 out of 3 staff stated that they document on the MAR when they give the medicines to the residents, and they have never missed a medication dose.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230908080341

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BRICKSTONE MANOR	FACILITY NUMBER: 198320096
	VISIT DATE: 09/12/2023

NARRATIVE

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During interviews with residents (R#1-R#3), 3 out of 3 stated that they are getting their medications as prescribed, and they have never missed a medication dose before or known if another resident missed their medication.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation are found to be UNSUBSTANTIATED.

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.

California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of the Complaint Report was given to Dadabhoy Muqeet/Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

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