198600525-8-2-2023-11-AS-MVAO-CULRBQ-20230811125309

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600525
Report Date: 08/02/2023
Date Signed: 08/02/2023 11:53:09 AM

Unsubstantiated

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
07/18/2023 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20230718092416

FACILITY NAME:	WESTSIDE MANOR		FACILITY NUMBER:	198600525
ADMINISTRATOR:	CHAVEZ, GABRIELA		FACILITY TYPE:	735
ADDRESS:	4836 WEST WASHINGTON BLVD.		TELEPHONE:	(323) 937-4506
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90016
CAPACITY:	136	CENSUS: 91	DATE:	08/02/2023
		UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Gabriela Chavez-Administrator		TIME COMPLETED:	11:52 AM

ALLEGATION(S):

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Resident was physically assaulted by an unknown perpetrator causing bruising.

INVESTIGATION FINDINGS:

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On 8/2/2023 LPA Alfonso Iniguez conducted and unannounced complaint visit. LPA Iniguez meet with Gabriela Chavez/Administrator. LPA explained the purpose of this visit. Today, LPA rendered findings from previous visit.

Investigation Consisted of: LPA conducted interviews with Clients(C#1-C#10), Administrator(A#1), and Staff (S#1-S#7) after 3 attempts, LPA was not able to get a hold of RP. LPA obtained and reviewed C#1-C#5 Admission Agreement, C#1-C#5 LIC 601, C#1-C#5 Medication Administration Record May, June and July 2023, C#1-C#5 Needs and Services Plans, C#1-C#5 LIC 602A, client roster, staff roster, written statement by staff that witnessed C#1 the day of the event, C#1 hospital discharge papers, house rule and C#1 Functional Capability Assessment,.

Evaluation Report Continues on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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-20230718092416

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: WESTSIDE MANOR	FACILITY NUMBER: 198600525
	VISIT DATE: 08/02/2023

NARRATIVE

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Allegation: Resident was physically assaulted by an unknown perpetrator causing bruising.

The details of the complaint alleged client went to hospital with facial bruises due to physical assault by an unknown perpetrator.

During record review, LPA reviewed C#1's Physicians report for residential care facilities for the elderly (LIC 602A). LPA found that C#1 is ambulatory, not confused, has not have a wondering or sun downing behavior, can follow instructions, and can leave the facility unassisted. The only assistance C#1 needs from staff is managing her medication. In addition, LPA reviewed C#1's functional capability assessment (LIC 9172); she does not need assistance with dressing, grooming, bathing, and other personal hygiene. Also, the appraisal needs and services plan (LIC 625) states that C#1 presents with adequate independent functioning skills and maintains satisfactory daily living activities. The discharge hospital summary says C#1 prior level of function C#1 was in functional mobility and ambulation with no AD. LPA reviewed C#1's admission agreement rules and stated that all residents should abide by the facility's general rules. LPA asked the administrator for a copy of the facility rules. The general facility rules states, "All residents are encouraged to be back at the facility by 11:00 PM for their own safety."

During an interview with administrator Gabriela Chavez (A#1), she stated that on 7/12/2023, around 6:30 AM received a phone call from one of the staff saying that she saw C#1 coming into the facility "bruised up." The staff asked C#1 what happened to her; she replied: "I need to go to my room and wash my face." Immediately, the staff stopped C#1 from going to her room and called paramedics. When I arrived at the facility, EMS was already taking C#1 to the hospital. That day, I called her family and primary physician to let them know what happened to her. After C#1 was discharged from the hospital, we have been taking a closer look on her. I have been speaking with her sister and primary physician, they both believe C#1 needs a higher-level care facility. On 7/25/23, C#1 primary physician came to assess her and update her LIC 602; he is still working on it. In addition, the facility's home health nurse, that comes Monday through Friday, already assessed C#1 after she was discharged from the hospital. LPA asked the administrator about facility rules regarding leaving the facility after late hours or curfew time; the administrator stated that since most of the residents are independent and not living in a locked facility, we cannot tell them not to go out; we can only encourage them not to go out to the street at later hours. The only residents with restricted hours are the ones with parole orders and sex offenders.

Evaluation Report Continues on LIC 9099C.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230718092416

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: WESTSIDE MANOR	FACILITY NUMBER: 198600525
	VISIT DATE: 08/02/2023

NARRATIVE

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During the interview with C#1, LPA asked her if she remembered what happened on 7/12/2023; C#1 stated that she went out at 8:00 AM, was walking down the street to get to the bus, and suddenly fell on the ground. C#1 stated that she fell on the ground several times, and a bystander called 911 to help her. C#1 said that when EMS arrived at the location where she was on the street, they cleaned her wounds and told her to go home, put on some cream and take her medication. LPA asked C#1 if she had been out since last night, C#1 denied being out all night. LPA also asked C#1 while she was outside, did someone physically attack you? C#1 responded, "No, nobody attacked me; I fell on the ground." LPA asked C#1 while she was in the hospital, did you mention to them that you were physically assaulted? C#1 responded: "I told them that I fell on the ground a few times, and that's it."

During interviews with clients (C#1-C#9), 9 out of 9 stated that they are independent. Also, 8 out of 9 stated that they do not require assistance from staff. 8 out of 9 said that while in the street, they never had any problems or were physically assaulted.

During interviews with staff (S#1-S#7), 7 out of 7 felt that facility staff adequately supervised clients, and 6 out of 7 knew about C#1’s incident.

During this investigation, LPA found did not find sufficient evident 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 UNSUBSTANTIATED.

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

California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of the Complaint Report was given to Gabriela Chavez/Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC9099 (FAS) - (06/04)

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