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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600052
Report Date: 08/16/2023
Date Signed: 08/16/2023 01:15:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
08/10/2023 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230810124220
FACILITY NAME:HERITAGE ADULT RESIDENTIAL KAREFACILITY NUMBER:
198600052
ADMINISTRATOR:ODUNOLA TAIWOFACILITY TYPE:
735
ADDRESS:640 WEST CALDWELL AVENUETELEPHONE:
(310) 763-2829
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY:6CENSUS: 4DATE:
08/16/2023
UNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Ruth AaronTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility staff failed to follow physicians orders.
Facility staff failed to report an incident.
INVESTIGATION FINDINGS:
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On 08/16/23, Licensing Program Analyst (LPA), Perry Scott conducted a 10-day complaint investigation visit at the facility listed above. LPA Scott met with Director, Ruth Aaron, and explained the purpose of today’s visit was to investigate the allegations listed above.

On 08/16/23, the investigation consisted of the following:

During today's visit LPA conducted interviews with staff and obtained documents from the facility which included: Staff and Resident Roster, ID/Emergency Information, SIR, and Physicians Reports for R1.

The investigation revealed the following: Regarding allegation #1 Facility staff failed to follow physicians’ orders.

On 08/16/23, LPA interviewed S1-S2. 2 of 2 staff confirmed that the resident has not had the procedures, prescribed by the physician, done because R1 gets agitated and can’t sit for the procedure. Although, R1 has had a follow up appointment, the prescribed procedures (MRI, CT scan, & Helmet) have not been completed.
Report continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
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-20230810124220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HERITAGE ADULT RESIDENTIAL KARE
FACILITY NUMBER: 198600052
VISIT DATE: 08/16/2023
NARRATIVE
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Based on LPA’s record review and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation: Facility staff failed to follow physicians’ orders are found to be substantiated. California Code of Regulations, Title 22, Division (6) and chapter (1) are being cited on the attached LIC 9099D.

Allegation #2: Facility staff failed to report an incident.

On 08/16/23, LPA interviewed S1-S2. 2 of 2 staff confirmed that they did not send an incident report to Community Care Licensing when an incident occurred with R1 in August-2022 that required R1 to be taken to the doctor. Both stated that they submitted a report to SCLARC but did not submit to CCLD.

Based on LPA’s record review and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation: Facility staff failed to report an incident are found to be substantiated. California Code of Regulations, Title 22, Division (6) and chapter (1) are being cited on the attached LIC 9099D.

Deficiencies were issued and an exit interview was conducted. Plans of corrections were developed. A copy of this report and appeal rights were given to Director, Ruth Aaron.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230810124220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE ADULT RESIDENTIAL KARE
FACILITY NUMBER: 198600052
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2023
Section Cited
CCR
80075(a)
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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not met as evidenced by:
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Facility will schedule all needed appointments to get the MRI, CT scan, and helmet for R1 by 09/16/2023 and send the proof to LPA Scott's email at perry.scott@dss.ca.gov.
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Based on records review and interviews, the facility failed to follow up on R1s prescribed medical treatment that included having an MRI, CT scan, and being fitted for a helmet. This violation poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/16/2023
Section Cited
CCR
80061(a)(b)
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(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency...This requirement is not met as evidence by:
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The facility will submit a plan of corrections that will show that all employees have been trained that whenever an incident ocurrs a report must be submitted to CCLD and SCLARC. This report, with the attendees, name and date must be submitted to LPA by 9/16/23 to perry.scott@dss.ca.gov
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Based on interviews and records reviewed, facility failed to submit an incident report to CCLD for R1 that ocurred in August-2022 that caused R1 to go to the hospital.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3