198320498-12-10-2024-11-AS-UCOL-DCBTUU-20241226140255

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320498
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:30:17 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, 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
12/04/2024 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20241204113346

FACILITY NAME:	GENERATIONS OF LOS ANGELES ASSISTED LVNG. FACILITY		FACILITY NUMBER:	198320498
ADMINISTRATOR:	CAMARIN JOHNSON		FACILITY TYPE:	740
ADDRESS:	3540 MARTIN LUTHER KING, JR.		TELEPHONE:	(310) 638-4113
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	178	CENSUS: 77	DATE:	12/10/2024
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	ADMINISTRATOR CAMARIN JOHNSON		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Unknown adult grabbed resident roughly causing injury
Staff did not get timely medical care for resident

INVESTIGATION FINDINGS:

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Community Care Licensing Division (CCLD) conducted an unannounced visit to Generations of Los Angeles Assisted Living Facility on 12/10/2024 and was greeted by Administrator Camarin Johnson (S1). CCLD staff explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

The investigation consisted of the following: CCLD staff interviewed Administrator (S1), staff (S1-S4), residents (R1-R8). CCLD staff requested and reviewed copies of the following: Physician Report (dated 09/23/2024), incident report (dated 12/02/2024), Needs and Service plan (dated 10/01/2024), pre-placement appraisal (date 09/23/2024). CCLD staff toured the facility with S1.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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-20241204113346

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: GENERATIONS OF LOS ANGELES ASSISTED LVNG. FACILITY	FACILITY NUMBER: 198320498
	VISIT DATE: 12/10/2024

NARRATIVE

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Regarding Allegation #1: Unknown adult grabbed resident roughly causing injury.

It is being alleged that R2 grabbed R1 shoulder and dislocated R1 right shoulder. CCLD staff toured the facility and noted R1 did not appear to have a dislocated right shoulder. R1 was moving both arms with no issues. CCLD staff reviewed pre-placement appraisal (date 09/23/2024), physician report (date 09/25/2024), needs and service plan (date 10/01/2024), incident report (date 12/02/2024) for R1. R1 has health issues and claims chronic shoulder pain. CCLD staff reviewed incident report for 12/02/2024, there is no claim of any injury to either resident. CCLD staff and S1 spoke to R1. S1 offered to take R1 to the hospital for the supposed dislocated shoulder, R1 refused. 4 out of 4 staff indicate that R1 and R2 yelled at each other and R2 never grabbed R1 shoulder. R1 indicates that R2 grabbed R1 right shoulder and dislocated R1 right shoulder. 7 out of 8 residents indicate that R2 never grabbed R1 shoulder.

Regarding Allegation #2: Staff did not get timely medical care for resident.

It is being alleged that staff did not get timely medical care for R1. CCLD staff toured the facility and noted R1 did not appear to have a dislocated right shoulder. R1 was moving both arms with no issues. CCLD staff reviewed pre-placement appraisal (date 09/23/2024), physician report (date 09/25/2024), needs and service plan (date 10/01/2024), incident report (date 12/02/2024) for R1. R1 has health issues and claims chronic shoulder pain. CCLD staff reviewed incident report for 12/02/2024, there is no claim of any injury to either resident. CCLD staff and S1 spoke to R1. S1 offered to take R1 to the hospital for the supposed dislocated shoulder, R1 refused. 4 out of 4 staff indicate that R1 never advised staff that R1 had a dislocated right shoulder on 12/02/2024 incident. S1 and S2 came to the incident scene and spoke to R1 and R2. Staff indicate that R1 or R2 claim any injury from the 12/02/2024 incident and if R1 had claimed R1 was injured staff would have called 911. R1 indicates that R2 grabbed R1 right shoulder and dislocated R1 right shoulder. R1 indicates that staff refused to take R1 to the hospital. 7 out of 8 residents indicate that R1 never advised them of any injury.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241204113346

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: GENERATIONS OF LOS ANGELES ASSISTED LVNG. FACILITY	FACILITY NUMBER: 198320498
	VISIT DATE: 12/10/2024

NARRATIVE

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Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “Unknown adult grabbed resident roughly causing injury”, “staff did not get timely medical care for resident” is found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Camarin Johnson S1.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC9099 (FAS) - (06/04)

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