198600187-11-17-2023-28-AS-LHIS-CY2L4H-20231129072530

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600187
Report Date: 11/17/2023
Date Signed: 11/17/2023 02:32:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210827131744

FACILITY NAME:	CHOICES R US - IZETTA		FACILITY NUMBER:	198600187
ADMINISTRATOR:	DANIEL GODFREY		FACILITY TYPE:	735
ADDRESS:	12103 IZETTA AVE		TELEPHONE:	(562) 869-5135
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY:	4	CENSUS: 4	DATE:	11/17/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Gil Martinez, Acting Administrator		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Questionable death.
Staff caused injuries to client in care.
Staff engaged in physical altercation with client.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations The purpose of the visit was explained to Acting Administrator Gil Martinez.

The investigation consisted of: On 8/30/2021, LPA Angelica Rea conducted a 24-hour health and safety check that included a physical plant tour of the facility and review of resident (R1's) file. LPA Rea did not obtain documents during the visit. On 8/31/2021, LPA Rea received an email from Administrator Daniel Godfrey with the following documents: Identification/ Emergency Information, IPP Reports, resident roster and staff roster. Administrator emailed LPA Galarza a copy of R1's Death Certificate on 9/9/2021. During the course of the investigation, Administrator (staff S4) Daniel Godfrey was interviewed. During today's visit, staff (S5) Acting Administrator and residents (R3- R4) were interviewed. Resident (R1) died on 5/16/2019 and resident (R2) was discharged from the facility on 4/8/2020; therefore not interviewed. Resident (R5) is deaf and non-verbal and was not interviewed. Staff (S4-S6) were interviewed. The South Central Los Angeles Regional Center was contacted.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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 28-AS-20210827131744

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHOICES R US - IZETTA	FACILITY NUMBER: 198600187
	VISIT DATE: 11/17/2023

NARRATIVE

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Allegation: Questionable Death. It is alleged that in early 2020 former staff (S1) was observed fighting and choking resident (R1) and afterwords the resident was observed unresponsive on the facility floor which resulted in the resident's death. On 5/17/2019, facility Administrator Daniel Godfrey submitted an incident report and LIC 624A Death Report. The incident report stated that on 5/16/2019 at approximately 5:15 PM, resident (R1) became upset because he wanted to speak via cell phone to a staff person referred to as "mother", but staff (S2) was not available. Therefore, the resident became frustrated and verbal aggression ensued. Staff redirected the resident, but at approximately 6:00 PM, the resident began to swing at staff (S3). The resident sat on the couch, and at approximately 6:08 PM while sitting on the couch the resident tilted it's head back and appeared to be gasping for air. At 6:12 PM, staff observed the resident to be unresponsive and immediately called 911. In the meantime staff performed CPR. At approximately 6:55 PM after numerous attempts by emergency response personnel the resident was pronounced dead. On 5/22/2019, LPA Galarza conducted a health and safety check and collected resident (R1's) file documents. as well as file documents of the two (2) staff that were present during the incident. File review indicated that resident (R1) had multiple health issues i.e. hypertension, seizure disorder, DM II, and Cancer.

Staff (S4-S6) and residents (R3 - R4) were interviewed. Staff interviews revealed that resident (R1) died on 5/16/2019 and not in early 2020. All interviewees stated that resident (R1's) death was not a result of staff choking the resident. During the course of the investigation, LPA contacted Administrator requesting the LA County Certificate of Death. On 9/9/2021, Administrator submitted a copy of the Certificate of Death. The cause of death was cardiopulmonary arrest, cardiac arrhythmia, probable pulmonary embolism, and metastatic cancer.

***Narrative continues next page.****

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210827131744

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHOICES R US - IZETTA	FACILITY NUMBER: 198600187
	VISIT DATE: 11/17/2023

NARRATIVE

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Allegation: Staff caused injuries to client in care. It is alleged that in late 2020 staff (S3) fought with resident (R2) which resulted in a cut to their lip and back pain. After the incident staff allegedly called Downey Police Department alleging that R2 was being aggressive with staff. Resident (R2's) file documents were reviewed. On 4/8/2020, resident (R2) became upset with job coach/staff (S3), verbally assaulting at first, and then hitting staff (S3) on lower jawbone. The staff quickly defended themselves and grabbed resident 9R2) by their shirt and placed them on the floor. Two other staff were present. According to staff interviews, the resident was not injured. The resident injured staff (S3). Administrator stated that the incident occurred on 4/8/2020. Per staff interviews and document review, the findings indicate that resident (R2) was highly agitated, hit staff, and then proceeded to walk to the kitchen to retrieve a 4 ½ inch pocket knife from an upper cabinet where the resident had hidden their knife. Staff tried to de-escalate the incident and a staff person was able to get the resident to surrender the the knife without incident. Downey Police Department responded, confiscated the knife, and took resident (R2) into custody. The findings indicate that the alleged incident is inaccurate. Based on resident and staff interviews resident (R2) was not injured. Residents and staff stated they felt threatened by resident (R2).

Allegation: Staff engaged in physical altercation with client. It is alleged that in late 2020 staff (S4) threw resident (R2) onto the fire place resulting in back injuries and the resident was transported to a local hospital. Based on interviews conducted, the alleged incident did not occur. The staff in question, staff (S4) stated they never had any physical encounters with any residents in the home. None of the residents interviewed had knowledge of the alleged incident. LPA observed the fireplace is approximately 1 ft above from the floor. Based on record review, there is no record of the alleged incident. In addition, resident (R2) was discharged from the facility on 4/8/2020 after the aforementioned incident in allegation #2. Therefore, there is insufficient evidence to corroborate the allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of this report was discussed and provided to Acting Administrator Gil Martinez.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC9099 (FAS) - (06/04)

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