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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320498
Report Date: 08/14/2024
Date Signed: 08/14/2024 05:44:58 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, 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
08/12/2024 and conducted by Evaluator Socorro Leandro
COMPLAINT CONTROL NUMBER: 11-AS-20240812153534
FACILITY NAME:GENERATIONS OF LOS ANGELES ASSISTED LVNG. FACILITYFACILITY NUMBER:
198320498
ADMINISTRATOR:CAMARIN JOHNSONFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: 58DATE:
08/14/2024
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator - Camarin JohnsonTIME COMPLETED:
05:50 PM
ALLEGATION(S):
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Staff did not ensure supervision was provided resulting in resident sustaining an unexplained injury while in care
INVESTIGATION FINDINGS:
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On 08/142024 at around 9:40 AM Licensing Program Analyst (LPA) Leandro conducted a complaint investigation regarding the allegation listed above. LPA met with the Administrator Camarin Johnson and the purpose of the visit was explained.

The investigation consisted of the following: During today’s investigation LPA and Administrator toured Resident 1s (R1) bedroom. LPA interviewed 4 out of 38 staff and attempted to interview R1. LPA reviewed facility records and R1’s records.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
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-20240812153534
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: GENERATIONS OF LOS ANGELES ASSISTED LVNG. FACILITY
FACILITY NUMBER: 198320498
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2024
Section Cited
CCR
87463(a)(1)(3)
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Reappraisal (a) The pre-admission appraisal shall be updated...to keep the appraisal accurate...Significant changes shall include...limited to: (1) A physical trauma..(3) Any..trauma, or change in the health care needs of the resident...
This requirement is not met as evidenced by:
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The Licensee will create a plan to update R1's Reappraisal, Appraisal/Needs And Services Plan to include a Fall Prevention Plan for R1. The LIcensee will also create a plan to assist R1 with attaining Durable Medical Equipment (DME) for
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Based on record review and interviews conducted the licensee did not comply with the section cited above in not having an updated Reappraisail and Needs and Services Plan to include R1's Fall Risk Prevention Plan which poses a potential health and safety risk to R1.
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example walkers, wheelchairs, devices that assist residents in their daily activities.

Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.
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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.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240812153534
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: GENERATIONS OF LOS ANGELES ASSISTED LVNG. FACILITY
FACILITY NUMBER: 198320498
VISIT DATE: 08/14/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation “Staff did not ensure supervision was provided resulting in resident sustaining an unexplained injury while in care” it is being alleged that R1 has a history of falls and head traumas; and the licensee has not created fall prevention plan for R1 and has not assisted R1 in attaining Durable Medical Equipment (DME) for example walkers, wheelchairs, devices that assist residents in their daily activities. Record review of R1’s medical history indicate that R1 fell on: 7/7/21, 10/19/21, 10/31/22, 12/3/22, 9/9/23, 6/8/23, 6/13/24, and 8/8/24. R1's medical history shows a history of head tramas due to falls. R1 was receiving physical therapy for the month of 09/2023 and medical documentation indicates “assistive device is needed” for example, “FWW” (front-wheeled walker) and that R1 is a fall risk. LPA did not observe a fall prevention plan for R1. R1’s Appraisal/Needs and Services Plan does not include fall prevention. Interviews conducted reveal the following: R1 does not have an assistive walking device and R1 does not have a fall prevention plan. Observations reveal the following: LPA did not observe durable medical equipment in R1’s bedroom but LPA did observe handrails in R1’s bathroom. Regarding the allegation “Staff did not ensure supervision was provided resulting in resident sustaining an unexplained injury while in care,” the preponderance of the evidence standard has been met therefore the allegation is substantiated.

Deficiencies cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Administrator along with their appeal rights.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
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