198320096-3-26-2024-11-AS-UCOL-D4FSFR-20240418135048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320096
Report Date: 03/25/2024
Date Signed: 03/26/2024 07:34:31 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
03/21/2024 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 11-AS-20240321125550

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: 5	DATE:	03/25/2024
		UNANNOUNCED	TIME BEGAN:	07:59 AM
MET WITH:	Edilberto Bernardino		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff do not ensure that resident's needs are met at night.

INVESTIGATION FINDINGS:

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On 03/25/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint visit. Upon arrival at the facility. LPA Richard met with staff Milagros Santos, Frederico Santos. LPA Richard explained the purpose of today's visit. Later was joined by administrator Edilberto Bernardino.

The investigation consisted of the following:
LPA Richard and administrator Bernardino toured the facility grounds, and interviewed Administrator, Staff (S1-S3) Resident (R3-R5) and witness (W1).
LPA Richard requested and obtained a Resident roster, staff roster, Admission Agreement, Medications (MAR), Needs of service plan, and Physician report for Resident care
LPA Richard requested and reviewed facility records.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

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 3

Control Number 11-AS-20240321125550

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: BRICKSTONE MANOR	FACILITY NUMBER: 198320096
	VISIT DATE: 03/25/2024

NARRATIVE

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Allegation: Staff do not ensure that resident's needs are met at night.

It was alleged that “staff do not ensure that resident’s needs are met at night.” On 03/25/2024, LPA Richard interviewed three (3) staff (S1-S3), three (3) residents (R3-R5) and one (1) witness (W1). LPA interview two residents (R1 and R2), but LPA was unable to obtain statements due to the residents’ medical conditions. Based on interviews with (S2 and S3), the facility has scheduled two staff at night. There always a staff around to provide and assist the resident when the resident ring the bell or move out the bed. The staff stated that not true and residents’ needs are being met. Staff (S1-S3) stated the facility ensure there is sufficient, trained, and competent staff to provide the services needed to meet resident’s needs. The administrator (S1) stated that the facility has one (1) Resident (R1) who was agitated at night, couldn’t sleep. In February the resident physician prescribed a new medication and increasing the doses of one of R1 medications now the resident (R1) is sleep through the night. Interview with residents (R3-R5), indicated that the staff provided them with their needs, and staff always around to assist them. LPA interview with witness (W1) stated that the problem with (R1) was resolved. The physician changes the medications and doses now, there is no more concerned about (R1), staff does ensure resident needs are met at night.

Continued LIC9099-C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240321125550

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: BRICKSTONE MANOR	FACILITY NUMBER: 198320096
	VISIT DATE: 03/25/2024

NARRATIVE

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Continue LIC9099-C

Based on observations, interviews and record review, there is no sufficient evidence to prove the above allegation. Although the allegations 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 unsubstantiated.

Exit interview conducted. A copy of the report was provided to the administrator Edilberto Bernardino.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC9099 (FAS) - (06/04)

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