198601211-3-2-2024-11-AS-EMAZ-D4GRYW-20240419132701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601211
Report Date: 11/16/2022
Date Signed: 03/02/2024 08:21:05 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
11/10/2022 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 11-AS-20221110151748

FACILITY NAME:	VILLA STANLEY		FACILITY NUMBER:	198601211
ADMINISTRATOR:	NATALIE SINGH		FACILITY TYPE:	735
ADDRESS:	335 N. STANLEY AVE		TELEPHONE:	(323) 937-4856
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90036
CAPACITY:	80	CENSUS: 68	DATE:	11/16/2022
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Manager, Vatsana Lopez and Administrator, Natalie Singh		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility has insects.

INVESTIGATION FINDINGS:

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This is an amended copy of the licensing report previously issued on 11/16/2022. The purpose of this amendment is to provide additional information only, it does not change the results of the investigation.

On 11/16/2022 Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced initial complaint visit to the facility. Upon arrival, LPA was greeted by the facility manager. The Administrator arrived shortly after, and LPA explained that the purpose of the visit was to investigate the above noted allegation.
It was alleged that facility has pests, flea, and bugs.
To investigate the allegation, during this visit at PA about 9:30am Alvizar conducted a tour of facility grounds, including kitchen, other common areas and residents’ bedrooms.
Prior to initiating interviews, LPA requested residents and staff roster and other documents relevant to investigation for review.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024

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 6

Control Number 11-AS-20221110151748

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: VILLA STANLEY	FACILITY NUMBER: 198601211
	VISIT DATE: 11/16/2022

NARRATIVE

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At approximately 10:05am LPA interviewed the Administrator, the manager, and two (02) other staff.
At approximately 10:35am LPA conducted interviews with seven (07) out of sixty-eight (68) Residents.
In addition, about 11:00am LPA interviewed a witness that could provide pertinent information.
The Administrator and other facility staff verified that facility has insects. Residents also indicated that there are bedbugs and roaches in the rooms.
During facility inspection LPA Alvizar found the following: in room #205 roaches on mattress. In the kitchen an insect glue trap with several dead roaches. Based on Inspection, observation and interviews, there is a sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Under California Code of Regulations, Title 22, Division 6, Chapter 1, the following citation was issued and recorded on LIC9099D.

Exit interview conducted and a copy of the appeal rights issued and discussed with Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 11-AS-20221110151748

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: VILLA STANLEY	FACILITY NUMBER: 198601211
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/16/2022 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	80087 Buildings and Grounds:The facility shall be clean, safe, sanitary:The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will continue the services of a pest control with Terminix company and more frequent cleaning on roaches targeted areas in the facility. Administrator will provide a written plan of action addressing sanitary conditions in residents rooms and written action plan will be faxed to CCL by 12/2/2022.
	8 9 10 11 12 13 14	Based on LPA observation during facility tour and resident interviews, The licensee failed to take measures to keep the facility free roaches. LPA found roaches on mattress in room #205 and in the kitchen, 6 out of 7 residents stated roaches are present in the facility. This poses a potential health & safety risk to residents in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

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
11/10/2022 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 11-AS-20221110151748

FACILITY NAME:	VILLA STANLEY		FACILITY NUMBER:	198601211
ADMINISTRATOR:	NATALIE SINGH		FACILITY TYPE:	735
ADDRESS:	335 N. STANLEY AVE		TELEPHONE:	(323) 937-4856
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90036
CAPACITY:	80	CENSUS: 68	DATE:	11/16/2022
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Manager, Vatsana Lopez and Administrator, Natalie Singh		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility did not ensure residents head lice was treated.
Staff are unable to effectively communicate with residents.
Facility is unsanitary.

INVESTIGATION FINDINGS:

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This is an amended copy of the Licensing report previously delivered on 11/16/2022
On 11/16/2022 Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced visit to facility. Upon Arrival LPA was greeted by the facility manager. The Administrator, Natalie Singh joined shortly after, and LPA explained the purpose of the visit.
Allegation 1. Facility did not ensure residents head lice was treated.
It was alleged that a Veteran that was transferred from the facility had lice. Many of the current residents had lice.
The Administrator and other staff revealed that when they made aware that R1 had lice, they immediately purchased lice shampoo and threated R1’s hair. Staff also revealed that Lice shampoo was available for all residents. However, some of them are not using it. Residents interviewed during the investigation confirmed that staff is providing shampoo for treatment but denied having lice.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 11-AS-20221110151748

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: VILLA STANLEY	FACILITY NUMBER: 198601211
	VISIT DATE: 11/16/2022

NARRATIVE

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Resident #5 (R5) indicated getting hair treated with lice shampoo. A review of the invoice for the purchase of Lice Shampoo supported the information revealed from the interviews.
Based on interviews observation and record review, there is no sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Allegation #2 Staff are unable to effectively communicate with residents.
It was alleged that most of the Villa Stanley staff doesn’t speak English. Residents and their families are having extreme difficulty communicating their needs and concerns to the staff.

During initial investigation, LPA Alvizar conducted a tour at about 9:30am of facility grounds, and at approximately 10:05am interviewed facility Manager, Administrator and two other staff. At approximately 10:35am LPA spoke with seven (07) out of sixty-eight (68) residents. At approximately 11:15am LPA reviewed facility records including purchase invoice for Lice Shampoo from MedRx Pharmacy and other supporting documents.

Administrator, and four (04) out of four (04) staff revealed that everyone working at the facility are able to communicate with the residents. Seven (07) out of (07) residents indicated that staff is able to communicate in English “really good” and they get along “really good".
Based on observation and interviews, there is insufficient information to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 11-AS-20221110151748

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: VILLA STANLEY	FACILITY NUMBER: 198601211
	VISIT DATE: 11/16/2022

NARRATIVE

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Allegation #3 Facility is unsanitary.
It was alleged that facility in general has unsanitary condition. Kitchen is filthy.
To investigate this allegation LPA Alvizar conducted a physical plant tour on 11/16/22 and at the time of subsequent visit. Facility appeared to be clean, and LPA observed housekeepers’ cleaning residents’ rooms.
Manager, Administrator and four (04) staff interviewed on date at approximately 10:05am stated that facility is clean, and they try their best to keep it in sanitary condition. Information revealed by (seven) (07) residents supported the information received from the staff.
Based on inspection, observation and interviews, there is no sufficient information to support the allegation. Therefore, the allegation is unsubstantiated at this time.
No immediate health and safety hazard is noted during this visit,

An exit interview was conducted. A copy of the Complaint Investigation Report was provided to Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024

LIC9099 (FAS) - (06/04)

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