198320119-9-21-2023-11-AS-UCOL-CWKMGH-20231013093556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320119
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:49:15 PM

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
06/23/2023 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230623125848

FACILITY NAME:	MONTOAK SENIOR LIVING INC.		FACILITY NUMBER:	198320119
ADMINISTRATOR:	SHAHEEN, NAJMA		FACILITY TYPE:	740
ADDRESS:	1700 248TH STREET		TELEPHONE:	(310) 406-6193
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	12	CENSUS: 11	DATE:	09/21/2023
		UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Najma Shaheen, Administrator		TIME COMPLETED:	03:09 PM

ALLEGATION(S):

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Due to lack of supervision, resident threatened another resident
Due to lack of supervison, resident hit another resident with a cane

INVESTIGATION FINDINGS:

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On 09/21/23, Licensing program Analyst (LPA) Mario Leon conducted an unannounced subsequent complaint visit to the facility. LPA was met by Najma Shaheen, Administrator (S1), who was informed that this visit was conducted to continue the investigation on the complaint allegations listed above.

The investigation consisted of the following:
On 06/26/23, LPA conducted an unannounced complaint visit at this facility. LPA toured the facility and LPA requested resident roster, staff roster. LPA interviewed four (4) residents, two (2) staff and one (1) witness.
On 09/21/23 LPA conducted a subsequent, unannounced, complaint visit at this facility. LPA toured the facility, interviewed 2 residents and re-interviewed the Administrator. LPA also requested further facility documents.

Report continues, see LIC9099C

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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-20230623125848

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: MONTOAK SENIOR LIVING INC.	FACILITY NUMBER: 198320119
	VISIT DATE: 09/21/2023

NARRATIVE

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The investigation revealed the following:

Regarding the allegation: Due to lack of supervision, resident threatened another resident.
It has been alleged that the abuser (R1) would utter bad words to R2 when she would walk near. R1 would threaten client constantly with her cane. On 06/26/23 LPA interviewed five (5) residents and three (3) out of 5 residents denied the allegation, 1 resident was unavailable for the interview. LPA interviewed two (2) staff and both staff have denied the allegation.
On 09/21/23 LPA interviewed 1 additional resident who denied the allegation. LPA also interviewed the licensee, Emma Parica (W2), where R1 had reportedly moved to. W2 verified that R1 had moved in. LPA requested and reviewed 1 further facility document which verified R1's exit from Montoak Senior Living facility on 06/29/23 by the Department of Mental Health Services exit form (DMHS-EF).

According to LPA's observations, interviews, and record reviews conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstantiated.

Regarding the allegation: Due to lack of supervision, resident hit another resident with a cane.
It has been alleged that R1 hit R2 on the ankle with a cane and that R2 had reported the incident to S1, without any repercussion. On 06/26/23 LPA interviewed five (5) residents and three (3) out of 5 residents denied the allegation, 1 resident was unavailable for the interview. LPA interviewed two (2) staff and both staff have denied the allegation.
On 09/21/23 LPA interviewed 1 additional resident who denied the allegation. According to the DMHS-EF, R1 has exited from Montoak Senior Living facility on 06/29/23 which shows removal of the reported behavior.

According to LPA's observations, interviews and record reviews conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstantiated.

An exit interview was held with Administrator, Najma Shaheen, and a copy of this report has been provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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