<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601604
Report Date: 03/17/2022
Date Signed: 03/17/2022 03:55:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/01/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210301085601
FACILITY NAME:CALIFORNIA MENTOR - 256TH HOMEFACILITY NUMBER:
198601604
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:1716 256TH STREETTELEPHONE:
(424) 263-4028
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:4CENSUS: 3DATE:
03/17/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Yvette Velasquez, DSPTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client sustained a fractured leg
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ana Soto and Jeremiah Randle made an unannounced visit to the facility and was greeted by Yvette Velasquez and later spoke with April Marshall, Program Supervisor via telephone. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Licensing Program Analyst (LPA) Ana Soto initiated the 10-Day Complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, the visit was conducted telephonically with Administrator (Stephanie Larin). LPA Soto requested copies of the following documents: face sheets, medication logs, admission agreements, physician's report, hospice notes, home health agency notes, emergency and identification information, house rules, and incident reports for Resident #1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
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-20210301085601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
VISIT DATE: 03/17/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During this virtual, video conference call with Administrator Larin, LPA Soto also conducted a virtual physical plant tour of the facility. A separate investigation was conducted by Department of Social Service Investigator (Douglas Real) which included review of medical records, hospital records, home health agency records, interview with facility staff and medical services staff.

Regarding Allegation #1: This investigation revealed that Resident (#1) (referred to as R1) sustained a displaced fracture to the left femur based on x-rays done on 02/28/21. Facility staff informed the hospital that Resident #1 did not have any falls or known trauma. Facility staff were aware of the discoloration (bruising) at the fracture site for several days (between 02/20/19 – 02/28/19); but unaware of the cause of the fracture. No other external injuries were found. Interviews conducted with the Regional Center’s Physician Assistant, RN, and LVN; including Resident #1’s primary care physician – who regularly saw the resident in the facility, none reported knowing the cause of the fracture nor did they suspect intentional abuse or neglect. Resident #1 is non-verbal and unable to provide any information; however, the primary care physician speculated that the injury was accidental and most likely occurred while facility employees transferred the resident into or out of bed with the Hoyer lift. No intentional abuse or neglect was uncovered during this investigation. Based on the evidence gathered and interviews conducted and records reviewed, did not concur with the above allegation.

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

An exit interview was conducted with Yvette Velasquez, DSP and a hard copy of report was provided.


SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/01/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210301085601

FACILITY NAME:CALIFORNIA MENTOR - 256TH HOMEFACILITY NUMBER:
198601604
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:1716 256TH STREETTELEPHONE:
(424) 263-4028
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:4CENSUS: 3DATE:
03/17/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Yvette Velasquez, DSPTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not properly trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ana Soto and Jeremiah Randle made an unannounced visit to the facility and was greeted by Yvette Velasquez, and later spoke with April Marshall, Program Supervisor via telephone. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Licensing Program Analyst (LPA) Ana Soto initiated the 10-Day Complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, the visit was conducted telephonically with Administrator (Stephanie Larin). LPA Soto requested copies of the following documents: face sheets, medication logs, admission agreements, physician's report, hospice notes, home health agency notes, emergency and identification information, house rules, and incident reports for Resident #1. During this virtual, video conference call with Administrator Larin, LPA Soto also conducted a virtual physical plant tour of the facility. A separate investigation was conducted by Department of Social Service Investigator (Douglas Real) which included review of medical records, hospital records, home health agency records, interview with facility staff and medical services staff.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210301085601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
VISIT DATE: 03/17/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding Allegation #3: this investigation revealed that the facility failed to provide licensing agency staff a copy of Resident #1’s Hoyer-lift Manual and training log pertaining to providing on-site, hands-on training to facility staff. Several attempts were made to request a copy of the Hoyer-lift Manual; and, it was documented that the facility had the Hoyer-lift Manual; but, could not be located nor documentation of the training log. Based on interviews conducted with Administrator Gabby did concur with the above allegation.

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Yvette Velasquez, DSP and a hard copy of Report and Appeal Rights provided

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210301085601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2022
Section Cited
CCR
85065(c)
1
2
3
4
5
6
7
85065(c)The licensee shall employ support staff as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.


1
2
3
4
5
6
7
The administrator shall provide a plan where Administrator will ensure to provide training to facility staff who assist residents with activities of daily living. The plan is due to the CCLD/El Segundo ASC Office by POC due date.
8
9
10
11
12
13
14
The standard of evidence was not met by; Based on the facility could not locate Resident #1’s Hoyer-lift Manual or facility staff training log for use of the Hoyer lift. Which poses a potential health and safety risk for persons 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5