198601962-3-16-2021-28-AS-MVAO-BZLQNM-20210330121922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 03/01/2021
Date Signed: 03/16/2021 03:16:35 PM

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 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
12/18/2020 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201218164406

FACILITY NAME:	SOUTHLAND LIVING		FACILITY NUMBER:	198601962
ADMINISTRATOR:	TRAN, VICTORIA		FACILITY TYPE:	740
ADDRESS:	11701 STUDEBAKER ROAD		TELEPHONE:	(562) 406-7326
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	75	CENSUS: 44	DATE:	03/01/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Victoria Tran		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility is not kept in good repair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicol Wesley conducted a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Victoria Tran.

The investigation consisted of the following: On 12/23/2020 LPA Wesley conducted a telephonic interview and requested copy of: staff roster, resident roster to be emailed/faxed by12/24/20. LPA also interviewed the Administrator Victoria Tran, and Residents 1-5(R1-R5).

Investigation revealed the following: During an interview with R1, LPA Wesley was asked by R1 "Why are you calling?" LPA Wesley explained the purpose for the call and R1 said: "The problem has been resolved!" LPA Wesley asked R1 if both items (windows and the AC unit) had been repaired/replaced and R1 said "everything
Continued on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021

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-20201218164406

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SOUTHLAND LIVING	FACILITY NUMBER: 198601962
	VISIT DATE: 03/01/2021

NARRATIVE

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is fine now" and wanted to end the call. Administrator Tran was interviewed and advised that R1 is non ambulatory and did report they were having issues with their window and AC unit. Administrator advised that the facility maintenance staff went to R1's room to replace the AC filter and service the unit, and to also check to make sure the window could open. Administrator said that R1 often complains about being hot and cold, so staff has to enter into R1's room to open/close the window or turn the AC on/off for them per their request, as they can not ambulate. Administrator also said the AC unit was replaced per R1's request, and admitted that the windows are older, but they are operable. The windows were in the process of being replaced, but since the pandemic the window project was placed on hold as it was not an emergency situation and also to avoid outside visitors from entering and exiting the facility. Administrator also advised that during this pandemic R1 did not like several staff to enter and exit their room. LPA Wesley interviewed resident #2-#5 who advised that they did not have any concerns with their AC unit or windows.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A telephonic exit interview was conducted with Administrator Victoria Tran, and a hard copy was provided via email to obtain signature. There are no citations issued, exit interview conducted.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021

LIC9099 (FAS) - (06/04)

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