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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600723
Report Date: 05/09/2024
Date Signed: 05/09/2024 10:03:36 AM

Substantiated


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
05/01/2024 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240501090147
FACILITY NAME:VAUGHN LIVING SERVICESFACILITY NUMBER:
198600723
ADMINISTRATOR:VAUGHN SR., DAVIDFACILITY TYPE:
735
ADDRESS:2516 WEST 80TH STREETTELEPHONE:
(323) 752-5226
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY:4CENSUS: 3DATE:
05/09/2024
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Damaun Lewis/StaffTIME COMPLETED:
10:03 AM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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On 5/9/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Damaun Lewis /Staff. LPA explained the purpose of this visit.


Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Client’s interviews (C#1-C#3), Reporting Party (RP), Staff Interview (S#1) and a complete facility tour with pictures taken by LPA during investigation.



Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
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 4
Control Number 11-AS-20240501090147
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: VAUGHN LIVING SERVICES
FACILITY NUMBER: 198600723
VISIT DATE: 05/09/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation: Facility is in Disrepair

The complaint details alleged that some areas in the facility are in disrepair.

During the records review, LPA Iniguez reviewed the pictures taken by (RP).

During a tour of the facility, LPA observed the same items in disrepair as shown in the pictures previously taken by (RP) on 4/30/24.

During a phone interview with the administrator (A#1), he reassured that client received ample support from him and the facility staff. Furthermore, (A#1) acknowledged the items in disrepair observed by LPA during the facility tour, and he expressed his commitment to rectify them within a fortnight.

During an interview with the client (C#1), they stated that they have lived at the facility for a long time. In addition, (C#1) said that they are receiving enough support from facility staff and administrators.

During an interview with Staff (S#1), they stated that clients are receiving enough support from facility staff and the administrator. On the other hand, (S#1) stated that the items observed by LPA during the tour of the facility are in disrepair, and they will fix them as soon as possible.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240501090147
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: VAUGHN LIVING SERVICES
FACILITY NUMBER: 198600723
VISIT DATE: 05/09/2024
NARRATIVE
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During this investigation, LPA found sufficient evidence 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 SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D)

An exit interview was conducted, and a copy of the Complaint Report was given to Damaoun Lewis/Staff.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240501090147
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: VAUGHN LIVING SERVICES
FACILITY NUMBER: 198600723
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2024
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds -
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement was not met as evidence by:
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Licensee will ensure facility is in good repair at all times. As Plan of Correction, licensee will replace/fix the items observed and mentioned by LPA before POC due date. A proof of the fixed items will be sent to LPA via email before POC due date.
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Based on a review of records, observation and interviews, the licensee failed to ensure facility is in disrepair (dilapidated crown molding around toilet seat, worn out legs in shower bench, broken toilet seat, rusted toilet paper holder, broken doorknob and rusted heat vent on the floor).

This poses a potential health and safety risk to all residents in care.
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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: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4