198601841-1-27-2023-28-AS-RORN-CNUNL4-20230208093254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601841
Report Date: 01/27/2023
Date Signed: 01/27/2023 11:31:23 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
01/07/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220107102317

FACILITY NAME:	DEVLIN FACILITY		FACILITY NUMBER:	198601841
ADMINISTRATOR:	LA MARR, KEISHA		FACILITY TYPE:	735
ADDRESS:	20516 DEVLIN AVE		TELEPHONE:	(562) 278-2127
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90715
CAPACITY:	3	CENSUS: 3	DATE:	01/27/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Tranae Gatlin - Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Residents are not being showered regularly

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted a subsequent unannounced complaint visit to deliver findings to the above mentioned allegation. LPA met with Administrator Baltazar Cornejo and explained the reason for the visit.

The investigation consisted of the following: On 01/13/2022, LPA obtained copies of resident and staff rosters, client shower in-service training dated 01/12/2022, December 2021 shower log. LPA also interviewed administrator, Client #1 - Client #3 (C1 - C3) and Staff #1 - Staff #3 (S1 - S3). Today's visit, LPA delivered findings.

The investigation revealed the following: regarding allegation “residents are not being showered regularly”, it is alleged the PM shift is not showering the clients on a regular basis. Interviews conducted with staff revealed that a shower log was created in the month of December 2021 because the issue was brought up to the program manager. (CONTINUED TO LIC 9099C)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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

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
01/07/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220107102317

FACILITY NAME:	DEVLIN FACILITY		FACILITY NUMBER:	198601841
ADMINISTRATOR:	LA MARR, KEISHA		FACILITY TYPE:	735
ADDRESS:	20516 DEVLIN AVE		TELEPHONE:	(562) 278-2127
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90715
CAPACITY:	3	CENSUS: 3	DATE:	01/27/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Tranae Gatlin - Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident developed a pressure injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted a subsequent unannounced complaint visit to deliver findings to the above mentioned allegation. LPA met with Tranae Gatlin (Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 01/13/2022, LPA obtained copies of resident and staff rosters, Client #2 (C2) turn/reposition records, C2 physician report, C2 Individual Program Plan (IPP) quarterly regional center report, C2 restricted health care plan and Excellence Home Health LVN notes regarding C2's pressure injury. LPA also interviewed administrator, Client #1 - Client #3 (C1 - C3) and Staff #1 - Staff #3 (S1 - S3). On 05/24/2022, LPA interviewed the Excellence Home Health LVN, representative from Harbor Regional Center and facility nurse. Today's visit, LPA obtained updated Excellence Home Health notes about C2 pressure injury and delivered findings.

The investigation revealed the following: regarding the allegation “resident developed a pressure injury while in care”, it is alleged that C2 developed a pressure injury while in care. (CONTINUED TO LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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 5

Control Number 28-AS-20220107102317

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: DEVLIN FACILITY	FACILITY NUMBER: 198601841
	VISIT DATE: 01/27/2023

NARRATIVE

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Records reviewed revealed that C2 has a history of skin integrity issues. C2 has a reoccurring Stage 1 ulcer on the buttocks from insufficient circulation to the area. The facility has a restricted health care plan on file for pressure injuries. Interview with the LVN from Excellence Home Health indicated that C2 had 2 pressure injuries on the buttock. One of the wounds has healed and the other wound is healing well. Repositioning logs were reviewed and documented that C2 is repositioned regularly. Interviews with staff revealed that C2 is repositioned every 2 hours and C2's wound is healing well. Regional center representative did not have any concerns about the wounds and confirmed home health visits C2 regularly. During today's visit, LPA reviewed Excellence Home Health notes dated 01/12/2023 stating that C2 bilateral buttocks noted to be clear, will continue on skin maintenance to prevent future breakdown. Based on the records and interviews there is insufficient evidence to prove the pressure injury developed due to neglect.

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.

Exit interview held and a copy of the report was provided

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20220107102317

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: DEVLIN FACILITY	FACILITY NUMBER: 198601841
	VISIT DATE: 01/27/2023

NARRATIVE

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During this time the administrator was out on leave from 11/10/2021 to 01/11/2022. The administrator was made aware of the clients not being showered and conducted an in-service training on 01/12/2022. Interviews with clients were unsuccessful due to the clients intellectual capabilities. Review of the December 2021 shower log showed that there were multiple days the clients did not receive a shower and the majority occurred in the PM shift. The shower log only indicates “no shower” and the shift where it occurred, but there is no explanation as to why a shower was not given or which client did not receive a shower.

Based on LPA's interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 6 are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20220107102317

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: DEVLIN FACILITY	FACILITY NUMBER: 198601841
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/28/2023 Section Cited CCR 85077(a)	1 2 3 4 5 6 7	85077 Personal Services (a) Licensees shall provide necessary personal assistance and care, as indicated in the needs and services plan, with activities of daily living including but not limited to dressing, eating, and bathing. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility is to ensure that Title 22 Section 85077 regulations are met at all times. Additionally, a statement indicating facility understands and will comply with Title 22 Section 85077 will be submitted to CCLD by 02/03/2023.
	8 9 10 11 12 13 14	Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. December 2021 shower log provided by the facility showed that clients were not shower on multiple days in the PM shift.	8 9 10 11 12 13 14	On 01/12/2022, the facility conducted an in-service training to address the no shower issues.
	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.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

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