198601841-5-11-2023-28-AS-RORN-CSBQNM-20230530121922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601841
Report Date: 05/11/2023
Date Signed: 05/11/2023 02:16:13 PM

Unsubstantiated

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
05/16/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220516115309

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:	05/11/2023
		UNANNOUNCED	TIME BEGAN:	01:32 PM
MET WITH:	Tranae Gatlin - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident needs a higher level of 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 05/24/2022, LPA requested a copy of client and staff roster, Client 1's (C1's) physician report, appraisal/needs and service plan, restricted health condition care plan, and regional center Individual Program Planning (IPP). LPA interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Regional Center Quality Assurance, Home Care Nurse and Facilty Nurse. On 05/11/2023, LPA delivered findings.

The investigation revealed the following: regarding allegation “resident needs a higher level of care”, it is alleged that C1 needs higher level care because C1 has become physically weaker and needs 2 staff to transferred him to the wheelchair. C1 can't feed himself, needs help swallowing, needs staff to hold the cup while drinking. C1 has had multiple pressure injuries, one was severe but has recently closed.
(Continued to LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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-20220516115309

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: 05/11/2023

NARRATIVE

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Interview with administrator and staff revealed that Joseph is able to feed himself, swallow and is able to transfer to wheelchair with minimal assistance. They stated that Joseph does have a wheelchair, but is able to walk around on his own and staff supervise C1. Staff confirmed that C1 does have a history of stage 1 pressure injuries on the buttocks, but a nurse from Nurse for Excellence Home Health comes regularly and staff reposition the client every 2 hours. Interview with Regional Center Quality Assurance Representative revealed that this facility is already a high level care and therefore C1 is at an appropriate facility. This facility is a specialized residential facility that provides services above Level 4i. They have consultants that come to the facility to assist with the clients' needs such as a facility nurse and behaviorist. Regional Center Quality Assurance Representative confirmed that a nurse from Excellence Home Health comes to the facility regularly to assist with the pressure injuries and staff have done a good job in repositioning C1. During today's visit, LPA observed C1 walking around and C1 was able to feed self.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC9099 (FAS) - (06/04)

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