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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601574
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:24:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
07/13/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230713143803
FACILITY NAME:CARTAGENA HOMEFACILITY NUMBER:
198601574
ADMINISTRATOR:PEARL LAMBFACILITY TYPE:
735
ADDRESS:1306 CARTAGENA STREETTELEPHONE:
(562) 988-8142
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:4CENSUS: 4DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Maria Christina, AdministratorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Resident had a choking incident due to staff neglect
INVESTIGATION FINDINGS:
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On 10/25/23 Licensing Program Analyst (LPA) Mario Leon conducted a subsuquent, unanounced, visit at the above facility and was met by Maria Christina, Administrator (S1). LPA and S1 took a tour of the facility.

The investigation consisted of the following:
On 07/17/23, LPA took a tour of the facility, inside and out, which was conducted with Maria Christina, Administrator (S1). LPA requested facility documents.
On 07/18/23, LPA interviewed four (4) out of fourteen (14) staff. LPA obtained further copies of the facility roster for residents, facility roster for staff and reviewed resident files for one (1) resident. LPA also reviewed hospital records for R1's visit.
On 09/25/23, LPA requested further documentation and interviewed four (4) additional staff out of fourteen (14) staff.
On 10/25/23 LPA arrived to further review records and deliver findings. LPA also interviewed one (1) witness (W1), via telephone, from Long Beach Memorial Hospital (LBMH). Report Continues, see LIC9099C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
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 5
Control Number 11-AS-20230713143803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CARTAGENA HOME
FACILITY NUMBER: 198601574
VISIT DATE: 10/25/2023
NARRATIVE
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The investigation revealed the following:

Regarding the allegation: "Resident had a choking incident due to staff neglect". It has been alleged that resident choked on a piece of broccoli that was fed to them not according to the prescribed diet.
On 07/17/23 LPA interviewed four (4) staff (S1-S4). Two (2) out of four (4) staff supported the allegation. On 07/18/23 LPA reviewed hospital documents which verify that R1 was struggling to breathe and that broccoli was removed, via forceps, five (5) minutes prior to arrival which resulted in hypoxia and an altered mental status. On 09/26/23 LPA interviewed four (4) additional staff (S5-S8). Out of the interviews conducted on 09/26/23, two (2) out of four (4) interviewees supported the allegation. On 10/25/23 LPA conducted an interview with W1 from LBMH who agrees that R1 aspirated on a diet sized too large. Therefore, five (5) out of nine (9) interviewees have supported the allegation. Interviews indicate that resident was being fed while lying in bed.
Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

An exit interview was conducted with Maria Christina, Administrator, a copy of the appeal rights and this report have been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230713143803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARTAGENA HOME
FACILITY NUMBER: 198601574
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2023
Section Cited
CCR
80076(a)(6)(A)
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80076 Food Services
(a) ..providing meals to clients, shall apply:
(6)Modified diets prescribed..as a medical necessity shall be provided.
(A)The licensee shall obtain and follow instructions from the physician or dietitian on the preparation of the modified diet.
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The LPA and Administrator have agreed that the staff will be trained by the dietician and LVN regarding aspiration, choking and that dietary restriction requirements are being met.
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This requirement has not been met as evidenced by record reviews indicate that on 07/01/23 a solid piece of broccoli was removed, further record reviews indicate that resident diet was not met. Interviews indicate that resident was being fed while lying in bed.
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Training will be provded to the staff during any change of dietary condition of residents within the various homes. Administrator will submit training evidence on, or prior to, POC due date as listed to MARIO.LEON@DSS.CA.GOV
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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: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
07/13/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230713143803

FACILITY NAME:CARTAGENA HOMEFACILITY NUMBER:
198601574
ADMINISTRATOR:PEARL LAMBFACILITY TYPE:
735
ADDRESS:1306 CARTAGENA STREETTELEPHONE:
(562) 988-8142
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:4CENSUS: 4DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Maria Christina, AdministratorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Staff did not provide resident’s medication records to hospital staff resulting in resident missing doses of prescribed medication
Staff falsified resident’s records
INVESTIGATION FINDINGS:
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On 10/25/23 Licensing Program Analyst (LPA) Mario Leon conducted a subsuquent, unanounced, visit at the above facility and was met by Maria Christina, Administrator (S1). LPA and S1 took a tour of the facility.

The investigation consisted of the following:
On 07/17/23, LPA took a tour of the facility, inside and out, which was conducted with Maria Christina, Administrator (S1). LPA requested facility documents.
On 07/18/23, LPA interviewed four (4) out of fourteen (14) staff. LPA obtained further copies of the facility roster for residents, facility roster for staff and reviewed resident files for one (1) resident. LPA also reviewed hospital records for R1's visit to Long Beach Memorial Hospital (LBMH) from 07/01/23 - 07/06/23.
On 09/25/23, LPA requested further documentation and interviewed four (4) additional staff out of fourteen (14) staff.
On 10/25/23 LPA arrived to further review records and deliver findings. LPA also interviewed one (1) witness (W1) via telephone from Long Beach Memorial Hospital (LBMH). Report Continues, see LIC9099C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230713143803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CARTAGENA HOME
FACILITY NUMBER: 198601574
VISIT DATE: 10/25/2023
NARRATIVE
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The investigation revealed the following:
Regarding the allegation: Staff did not provide resident’s medication records to hospital staff resulting in resident missing doses of prescribed medication. It has been alleged that the facility did not provide the MAR to Long Beach Memorial HospItal (LBMH). On 07/17/23 LPA interviewed four (4) staff (S1-S4). On 09/26/23 LPA interviewed four (4) additional staff (S5-S8) and one (1) witness. None (0) of the eight (8) staff have agreed with the allegation. On 10/25/23 LPA called LBMH and spoke with witness number one (W1) to interview whether R1 had received their daily medication while residing at the hospital from 07/01/23 - 07/06/23. W1 verified all six (6) medications as listed on R1's Medication Admissions Record were provided appropriately.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation: "Staff falsified resident’s records". It has been alleged that the incident report states that R1 was admitted to the hospital due to pneumonia, but in reality it was due to choking on food that should not have been given to her. On 07/17/23 LPA interviewed four (4) staff (S1-S4). On 09/26/23 LPA interviewed four (4) additional staff (S5-S8). None (0) of the eight (8) staff have agreed with the allegation and all agree that they are mandated reporters and understand they are able to report directly to Community Care Licensing regarding any violation of any resident or staff's rights. Record reviews revealed that the initial incident report was corrected following reception of discharge paperwork from LBMH and both copies were provided to Community Care Licensing.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was conducted with Maria Christina, Administrator, and a copy of this report has been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5