198320119-1-12-2024-11-AS-MVAO-CZJV5M-20240116150811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320119
Report Date: 01/12/2024
Date Signed: 01/12/2024 10:39:49 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
03/28/2022 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20220328160608

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: 12	DATE:	01/12/2024
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Najma Shaheen/Administrator		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Staff did not report incident to licensing.
Staff inappropriately touched resident while in care.

INVESTIGATION FINDINGS:

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On 1/12/2024, Licensing Program Analysts (LPA) Alfonso Iniguez conducted a subsequent complaint visit at this facility to deliver the complaint investigation findings. LPA met with the Licensee/Administrator Najma Shaheen, who assisted with the visit. The purpose of the visit was explained.

The investigation consisted of the following: On 3/30/2022, LPA Don Senaja conducted a 10-day initial complaint visit. LPA interviewed Administrator, Staff and Residents. LPA obtained copies of Staff Roster (LIC 500), Register of Facility Clients/Residents (LIC 9020), Resident’s Admission Agreement, Physician’s Report, Appraisal & Needs Services Plan, Medication Administration Records (MAR) and a Copy of SRI dated on 2/8/2022.

Report continued in LIC 9099C

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: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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-20220328160608

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: MONTOAK SENIOR LIVING INC.	FACILITY NUMBER: 198320119
	VISIT DATE: 01/12/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff did not report incident to licensing.

The details of the complaint alleged that facility staff did not report an incident to licensing.

During records review, LPA Iniguez observed Special Incident Report (SRI) regarding (R#1) event dated on 2/8/2022. A copy if the SRI was provided to LPA Iniguez during this visit.

During an Interview with Administrator (A#1), she stated that she did report to CCLD the incident through an SRI.

Allegation: Staff inappropriately touched resident while in care.

The details of the complaint alleged that facility staff inappropriately touched a resident while in care.

During an Interview with Administrator (A#1), she stated that (R#1) told her that they were touched inappropriately by (S#1) approximately one month ago on 3/30/2022. (A#1) told (R#1) that they would be assisted by (S#2). In addition, (A#1) stated that it needed (2) staff to assist (R#1) with her ADLs, (R#1) was always assisted by (2) staff members, (R#1)
was never alone with (1) staff.

During an Interview with Staff (S#1-S#2), (2) out of (2) stated that they have never touched a resident inappropriately, and they have never touched a resident in their private areas. Also, (2) out of (2) stated that they had never seen another staff inappropriately handling the residents.

Report continued in LIC 9099C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20220328160608

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: MONTOAK SENIOR LIVING INC.	FACILITY NUMBER: 198320119
	VISIT DATE: 01/12/2024

NARRATIVE

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During interviews with Residents (R#1-R#9), (6) out of (9) stated that no staff had ever inappropriately touched them. (2) out of (9) were sleeping during the time of the visit.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) 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 Najma Shaheen /Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC9099 (FAS) - (06/04)

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