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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320283
Report Date: 06/24/2024
Date Signed: 06/24/2024 04:34:29 PM

Substantiated


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
04/05/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240405160953
FACILITY NAME:VERNON COTTAGEFACILITY NUMBER:
198320283
ADMINISTRATOR:UMANA, JOSEFACILITY TYPE:
740
ADDRESS:2312 ROSWELL AVETELEPHONE:
(562) 342-6145
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: 5DATE:
06/24/2024
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Elsa Roman, Assistant AdministratorTIME COMPLETED:
05:02 PM
ALLEGATION(S):
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Licensee does not allow resident to participate in private visitations while in care.
Licensee is not allowing resident to participate in outings with family member(s).
INVESTIGATION FINDINGS:
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On 06/24/2024, Licensing program Analyst (LPA) Mario Leon conducted a follow-up, unannounced, visit to the above-mentioned facility to deliver this amended document originally delivered on 04/25/2024. LPA was met by Elsa Roman, Assistant Administrator.
The investigation consisted of the following:
On 04/10/2024, Licensing program Analyst (LPA) Mario Leon conducted an initial complaint visit at the above-mentioned facility. LPA was met by Alexander Ramos, Caregiver (S2). LPA was later met by Elsa Roman, Administrator (S1), and the purpose of the visit was explained. On 04/10/2024 LPA requested facility documents for all staff who were present during resident one's (R1) presence and R1's hospice care plan. LPA interviewed four (4) staff who were present at the facility and three (3) out of six (6) residents. 3 residents were not available for interview. LPA interviewed two (2) witnesses. LPA conducted a plant inspection and records were reviewed.

Report continues, see LIC9099C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
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-20240405160953
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: VERNON COTTAGE
FACILITY NUMBER: 198320283
VISIT DATE: 06/24/2024
NARRATIVE
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The investigation revealed the following:
Regarding the allegation: "Licensee does not allow resident to participate in private visitations while in care". It has been alleged that the Administrator, Jose Umana (S3), is not allowing resident one (R1) to have private visitations in his room.
Record Reviews of the Provider Information Notices (PINs), PIN 21-48-ASC indicate that: “individuals who have Power of Attorney (POA), regarding both financial and health directive has no legal authority to control resident’s visitation rights, unless explicitly specified in the POA document and if the resident is not objecting. The resident has ultimate authority over such decisions.”. LPA did not observe any court order which would restrict family members from visiting R1. Interviews with R1 indicate that R1 is ok with private visits with family member(s), that R1 holds no preference as to who they hold private visits with, as well as having no preference as to who they can go with on any private outings. Records review of the POA documents indicate that there are no specific authority of control of a resident’s visitation rights.
Interviews revealed that 4 out of 4 facilities’ staff claims to have followed a choice to disrupt a visit, based on the POA’s request. 3 out of 3 residents and 2 out of 2 witnesses have denied the allegation
Based on record reviews, interviews conducted and LPA’s observation, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.
Regarding the allegation: "Licensee is not allowing resident to participate in outings with family member(s).". It has been alleged that S2 is no longer allowing R1 to leave the facility with family member(s).
Interviews revealed that 4 out of 4 staff, 3 out of 3 residents and 2 out of 2 witnesses have denied the allegation. While R1 has stated that they are O.K. to conduct outings with their family member(s), it has been recommended by the Power of Attorney (POA) that R1 should not be let out of the facility, for fear of relocation of R1.
Record reviews revealed that, according to Provider Information Notices (PINs), PIN 21-48-ASC, R1 cannot be placed in a facility with secured perimeters. According to Health and Safety, Division 2 – Licensing Provisions, Chapter 3.2 Residential Care Facilities for the Elderly, Article 6.6 Secured Perimeters, 1569.698 (f) Any person who is not a conservatee and is entering a locked or secured perimeter facility pursuant to this section shall sign a statement of voluntary entry. The facility shall retain the original statement and shall send a copy of the statement to the department. R1 has not signed a voluntary entry for any secured perimeter facility and has not objected to conduct outings with family member(s).
Report continues, see LIC9099C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240405160953
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: VERNON COTTAGE
FACILITY NUMBER: 198320283
VISIT DATE: 06/24/2024
NARRATIVE
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Based on record reviews and LPA observation, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated.
California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

An exit interview was conducted with Elsa Roman, Assistant Administrator, and a copy of the appeal rights and this report has been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240405160953
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: VERNON COTTAGE
FACILITY NUMBER: 198320283
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to...87468.1, Personal Rights of Residents in All Facilities, residents...shall have all of the following personal rights:
(1) To have a reasonable level of personal
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Licensee has agreed to conduct in-staff training at the above-mentioned facility. All staff will read, in a language they understand, CCR 87468.2(a)(1-7) and licensee will provide a sign-in sheet, date(s)/time(s) included. Each staff will also review PIN 21-48-ASC and will sign names as "reviewed".
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privacy in...visits, communications, telephone conversations,...and family groups.
This has not been met as evidenced by: Licensee has agreed to follow the POA wishes by informing POA any time another family member arrives to visit with R1.
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Licensee will send sign-in sheet to LPA via email at MARIO.LEON@DSS.CA.GOV
Type B
06/28/2024
Section Cited
HSC
1569.698(f)
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1569.698 Building standards; adoption; locked and secured perimeters in residential care facilities; persons with dementia
(f) Any person who is not a conservatee...shall sign a statement of voluntary entry. The facility shall retain the original statement and shall send a copy
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Licensee has agreed to conduct in-staff training at the above-mentioned facility. All staff will read, in a language they understand, HSC 1569.698(f) and licensee will provide a sign-in sheet, date(s)/time(s) included. Licensee will send sign-in sheet to LPA via email at MARIO.LEON@DSS.CA.GOV
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of the statement to the department.
This has not been met as evidenced by: Licensee did not allow a family member to take R1 on outings.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4