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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320375
Report Date: 06/05/2025
Date Signed: 06/05/2025 10:22:31 AM

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
02/05/2025 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250205121215
FACILITY NAME:CIELAFACILITY NUMBER:
198320375
ADMINISTRATOR:SHRAM, RONYFACILITY TYPE:
740
ADDRESS:17310 WEST VEREDA DELA MONTURATELEPHONE:
(917) 667-5303
CITY:PACIFIC PALISADESSTATE: CAZIP CODE:
90272
CAPACITY:100CENSUS: 54DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Rony Shram/Executive TIME COMPLETED:
10:21 AM
ALLEGATION(S):
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Staff are not distributing a resident's medication as prescribed
INVESTIGATION FINDINGS:
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This report supersedes the reports created on 4/16/25, the findings remain the same.

On 06/05/2025 Licensing Program Analyst-LPA Alfonso Iniguez conducted a subsequent complaint visit at the facility. LPA Iniguez met with Rony Shram/Executive Director and explained the purpose of today’s visit.

Investigation consisted of the following: The Department conducted interviews with Residents (R2-R4) and Staff (S1-S3). LPA obtained R1 Medication Administration Records (Dated: 02/2025), Physicians Order for Medication (Dated: 05/17/2024), Physicians Report (Dated 06/20/2024), Face Sheet, Resident Appraisal, Identification and Emergency Information. The Department obtained R1 - R4 Physicians Report, Medication Administration Records (Dated 02/2025), and Physicians Order for Medications. LPA obtained copies of Med Tech training. LPA obtained copies of Register of Facility Residents, and Personnel Report.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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-20250205121215
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: CIELA
FACILITY NUMBER: 198320375
VISIT DATE: 06/05/2025
NARRATIVE
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This report supersedes the reports created on 4/16/25, the findings remain the same.

Investigation Revealed the Following:

Allegation: Staff are not distributing a resident's medication as prescribed.

The Department conducted an interview with Administrator Rony Shram, who stated he conducted an internal investigation, in January 2025, after learning that R1 experienced a Medication Administration error while residing in the facility from July 2024 to February 2025. Administrator Shram reported R1 received (1) tablet of Namenda 10 mg per day after an E-MAR system change occurred in July 2024. R1's physicians order reflected (1) tablet of Namenda 10 mg (2) times per day and the second tablet was not administered after the system change as the new E-MAR did not reflect the order for the second tablet. Administrator Shram self-reported the error and submitted an Unusual Incident Report (UIR) to CCL on January 29, 2025. The Department conducted interviews with LVN Wendy Cuadle (S1), who confirmed R1 received (1) tablet of Namenda 10 mg one time per day after the E-MAR system change occurred in July 2024. The Department interviewed Residents R2-R4 and found 3 of 3 Residents expressed no issues with staff assistance with Medication Administration. The Department interviewed Staff/Med Techs (S2-S3). S2-S3 stated Medication Administration training is provided prior to Med Techs administering medication independently. The Med Techs interviewed stated they administer and record passing medication on the E-MAR. The Med Techs interviewed stated they follow protocols per their training. The Department obtained and reviewed R1 physician's order (Dated:5/17/24) and R1's Medication Administration Records (Dated August 2024-Febuary 2025). The Department confirmed R1 received only (1) tablets of Namenda (Generic name: Memantine) 10 mg per day starting in August 2024 - February 2025.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20250205121215
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: CIELA
FACILITY NUMBER: 198320375
VISIT DATE: 06/05/2025
NARRATIVE
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This report supersedes the reports created on 4/16/25, the findings remain the same.

During this investigation, LPA found sufficient evidence to support the above-mentioned allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).

An exit interview was conducted, and a copy of the Complaint Report was given to Name/Executive Director.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20250205121215
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: CIELA
FACILITY NUMBER: 198320375
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2025
Section Cited
CCR
87208(a)
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87208 Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49.

This requirement was not met as evidence by:
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Licensee will adhere to Title 22 at all times. As part of the plan of correction, the licensee will conduct regular audits of medications, changes to the pharmacy, and retraining of facility staff, and will also bring in an outside consultant to oversee and regularly audit. A plan of correction will be submitted to LPA Inguez via email before the POC due date.
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Based on a review of records and interviews conducted, the department found R#1 received only 1 of 2 tablets of prescribed medication (Generic name: Memantine) per day from August 2024 through February 2025.
This poses an immediate health and safety risk to all residents in care.
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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: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4