198601785-10-18-2024-11-AS-JHAD-DB32RU-20241115163806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601785
Report Date: 09/26/2024
Date Signed: 10/18/2024 01:28:14 PM

Unsubstantiated

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
06/28/2024 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20240628150810

FACILITY NAME:	SPECIALIZED RESIDENTIAL 118TH STREET		FACILITY NUMBER:	198601785
ADMINISTRATOR:	SANDRA MORAGA		FACILITY TYPE:	735
ADDRESS:	5424 W 118TH ST		TELEPHONE:	(909) 287-3557
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90304
CAPACITY:	3	CENSUS:	DATE:	09/26/2024
		UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Cesar Monge, House Lead		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Facility staff handled client in a rough manner resulting in multiple bruises

INVESTIGATION FINDINGS:

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This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 9/26/24.

On 9/26/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by House Lead, Cesar Monge, and explained the purpose of the visit is to deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 07/01/2024, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Troy Watson conducted an unannounced complaint investigation at the facility listed above and requested and received copies of the following records: 3 client records, 2 staff records and facility records. Which includes the following Clients: admission agreements, Behavioral reports, incident reports and MAR (Apr-June). Staff LIC501, initial and annual trainings and facility staff schedule for June 2024. On 9/5/24 LPA Shirley interviewed S1-S7, and R1-R3 and requested and received, CPI records, Appraisal/Needs and Services, IPP, internal communications, and body checks.
Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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 11-AS-20240628150810

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: SPECIALIZED RESIDENTIAL 118TH STREET	FACILITY NUMBER: 198601785
	VISIT DATE: 09/26/2024

NARRATIVE

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The investigation revealed the following:

Allegation: Facility staff handled client in a rough manner resulting in multiple bruises

On 9/5/24, LPA Felisa Shirley reviewed facility files. Upon review of body checks, LPA observed the comments section on 6/22/24 completed after dialysis appointment. Comments section stated that, “Once back from dialysis around 9:50am vitals were taken, at this time multiple bruising was noted on both right and left arms.” LPA Shirley also observed body check dated 6/23/24, comments section stated that, LPT noticed bruising on the resident’s upper forearms, right calf, and abdomen. The resident explained that she fell out of bed and that’s how she got the bruises. She didn’t seem to be in any pain or discomfort. On body check dated 6/24/24, the comments section stated, “No new bruises and the old bruises are getting better.”

On 9/5/24, LPA Felisa Shirley reviewed C-1’s IPP plan and learned that C-1 goes to dialysis three times a week, Mondays, Wednesdays and Fridays. Per IPP, C-1 is resistive to going to dialysis and states that dialysis is boring and it hurts. LPA Shirley learned that per IPP, C-1 has a history of emotional outbursts, physical aggression, and non-compliance and fabrication. On 9/18/24, LPA spoke with C-1’s Westside Regional Center Service Coordinator and they stated that C-1 has a history of falls that’s not indicated on the current IPP but will make sure to include fall history on next evaluation for IPP.

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20240628150810

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: SPECIALIZED RESIDENTIAL 118TH STREET	FACILITY NUMBER: 198601785
	VISIT DATE: 09/26/2024

NARRATIVE

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LPA interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA ask, if staff handle clients in a rough manner.” Of those interviewed, 7 out of 7 answered no. LPA interviewed Resident-1 thru Resident-3 (R-1 thru R-3). LPA ask, Has anyone been aggressive with handling you?” Of those interviewed, 3 out of 3 answered no. 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. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff neglect resulted in a resident sustain multiple pressure injuries while in care” therefore the allegation is unsubstantiated.

No deficiencies issued during this visit.

An exit interview was conducted with House Lead, Cesar Monge and a copy of this report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC9099 (FAS) - (06/04)

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