198601446-12-7-2023-28-AS-RORN-CYGUED-20231213143055

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601446
Report Date: 12/07/2023
Date Signed: 12/07/2023 09:40:36 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/02/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230502083634

FACILITY NAME:	GATEWAYS NORMANDIE VILLAGE EAST		FACILITY NUMBER:	198601446
ADMINISTRATOR:	SANDY LONG		FACILITY TYPE:	735
ADDRESS:	1355 SOUTH HILL STREET		TELEPHONE:	(213) 389-5820
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90015
CAPACITY:	60	CENSUS: 52	DATE:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Nuri Sanchez		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff are discriminating against resident

INVESTIGATION FINDINGS:

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***This report supersedes the previous complaint report dated 07/28/23. The reason it’s being superseded is to correct the citations previously issued on 7/28/23. All findings remain the same. ****

Licensing Program Analyst (LPA) Wong conducted a subsequent complaint visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the finding. LPA met with Staff Thania Pulido who allowed entry into the facility and was later met by Administrator Alexander Rojas who assisted with the visit.

The investigation consisted of the following: On 5/9/23, LPA conducted the initial 10 days complaint visit and LPA interviewed five clients (C1-C5), administrator, intake, and discharge coordinator and two staff (S1-S2) and obtained document for C1.

(See LIC 9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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-20230502083634

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GATEWAYS NORMANDIE VILLAGE EAST	FACILITY NUMBER: 198601446
	VISIT DATE: 12/07/2023

NARRATIVE

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The investigation revealed of the following: Allegation “Staff are discriminating against resident”
C1 reported C1’s family brought a 30 inches television and facility staff told C1 was not able to keep the television because the facility was only allowed 24 inches or smaller television due to clients may use the television as a weapon for physical violence. During the tour of the facility, LPA observed few clients in the facility, and they have over 24 inches TV in their rooms. Facility staff reported it was approved mistakenly by their therapists. The administrator stated that they do not have anything in writing from the admission agreement or plan of operation which was not allowed over 24 inches Television in clients rooms, but it was in place since he worked there. Additionally, while LPA interviewed C1, it was reported C1 was not allowed to go out from the facility. LPA interviewed the program director and administrator and reported, when a client breaks the house rules or is tested positive for drug use, the client will be placed on a restriction (encourage to not leave the facility) for certain number of days. The facility implements this policy due to the background of these clients and to keep them safe. The clients are part of a Department of Mental Health program that works with clients to follow rules, gain independence, and transfer to another board and care with less restrictions. The facility staff stated that the facility is not locked and even though clients are on a restriction, they are not forced to remain at the facility.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. Refer to LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided to Administrator Alexander Rojas.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230502083634

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GATEWAYS NORMANDIE VILLAGE EAST	FACILITY NUMBER: 198601446
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/14/2023 Section Cited CCR 85072(b)(6)	1 2 3 4 5 6 7	85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights. (6) To possess and use his/her own personal items, including his/her own toilet articles.	1 2 3 4 5 6 7	Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. License to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	The requirement was not met as evidenced by Client's interviews and LPA's observation and reported that some residents can have over 24 inches television, and some cannot have it which posed a potential risk to clients in care.	8 9 10 11 12 13 14
Type B 12/14/2023 Section Cited CCR 80072(a)(5)(6)	1 2 3 4 5 6 7	80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. (6) To leave or depart the facility at any time.	1 2 3 4 5 6 7	Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. License to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	The requirement was not met as evidenced by Client's interviews and client stated that the staff does not allow client to go out from the facility and not allowed to go to church.	8 9 10 11 12 13 14

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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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