198320353-10-2-2023-11-AS-UCOL-CYERFZ-20231211115959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320353
Report Date: 10/02/2023
Date Signed: 10/02/2023 11:51:07 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, 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
09/15/2023 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 11-AS-20230915095946

FACILITY NAME:	HARVARD HOPE HOUSE		FACILITY NUMBER:	198320353
ADMINISTRATOR:	COXSOM, AMBER		FACILITY TYPE:	740
ADDRESS:	4239 S. HARVARD BLVD		TELEPHONE:	(323) 812-0788
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90062
CAPACITY:	6	CENSUS: 1	DATE:	10/02/2023
		UNANNOUNCED	TIME BEGAN:	08:17 AM
MET WITH:	Coxsom, Amber		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility forced resident into choosing another agency.

INVESTIGATION FINDINGS:

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On 10/01/2023, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to deliver findings regarding the above allegation. LPA Richard met with Administrator Coxsom Amber and explained the reason for the visit. LPA and Licensee toured the facility.

The investigation consisted of the following:
On 09/21/2023, LPA Richard and Coxsom conducted a tour of facility grounds, and interviewed Administrator, Staff (S1) and Resident (R1)
LPA Richard requested and obtained a Resident roster, staff roster, a Resident Notice of Proposed Transfer and Discharge, Admission Agreement, Patient Profile, Change Of Designated Hospice Provider, and Identification and Emergency Information.
LPA Richard requested and reviewed R1 records, staff and client's records.

Report Continues, See LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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-20230915095946

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: HARVARD HOPE HOUSE	FACILITY NUMBER: 198320353
	VISIT DATE: 10/02/2023

NARRATIVE

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Allegation: Facility forced resident into choosing another hospice agency.

On 09/31/2023 at 3:26 PM, LPA Antonine Richard interviewed Brian Peters, ( W1) son of the alleged Victim/Resident: Regina Wright Peters DOB: 07/14/1944. Peters stated that on 09/09/23, he replaced All in one Hospice Care with Faith and Hope Hospice Care, because All in one Hospice Care didn't show up at Harvard Hope House on the day of admission. All in One Hospice didn't send a nurse to help his mother moving into the facility. On 10/02/2023, LPA interviewed the Licensee (S1), who said she called All in One Hospice Care on 09/05/2023, to let them know the resident was at the facility. They told her they would send a nurse tomorrow. Then on 09/09/2023, Peters decided to call Faith and Hope Hospice to come and help his mother move and sign the documents to Harvard Hope house. During file review, LPA found that Resident 1 (R1) was admitted to Harvard Hope House on 09/05/2023, waiting for All in One Hospice Care to come at the facility. During file review, LPA Richard found facility sign- in sheet and noted that on 09/6/2023 and 09/11/2023, All in one Hospice Care Nurse (LVN) sign in at Harvard Hope House to review medications only. The Licensee stated that All in One Hospice care didn't leave any binders with the plan of care or written orders for the patient. LVN stated the facility has to wait for the Registered Nurse (RN) to help with sign-in.
Peters stated they were mad because we switched them to Faith and Hope Hospice Care, we were happy about doing it my mother needed help immediately. The Harvard Hope House was a great help to my mother. They didn't force my family to switch to another Hospice Care.

Based on interviews with staff, witness, and records reviewed from investigation there is insufficient
evidence to support the allegation: Facility force resident into choosing another hospice agency. Although the allegation 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.

Based on the information gathered, records reviewed and interviews conducted, the Department found no evidence to support the allegation mentioned in the complaint.

An exit interview was conducted with Licensee Coxsom Amber and a copy of the report was provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC9099 (FAS) - (06/04)

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