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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 05/04/2022
Date Signed: 05/10/2022 05:33:31 PM

Substantiated


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
01/26/2022 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220126164202
FACILITY NAME:SOUTHLAND LIVINGFACILITY NUMBER:
198601962
ADMINISTRATOR:TRAN, VICTORIAFACILITY TYPE:
740
ADDRESS:11701 STUDEBAKER ROADTELEPHONE:
(562) 406-7326
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:75CENSUS: 48DATE:
05/04/2022
UNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Victoria TranTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility did not safeguard resident's mail package.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced initial complaint visit and met with Administrator Victoria Tran, Wellness Director Michelle Adams to discuss the purpose for todays visit.

The investigation consisted of the following: LPA interviewed Administrator Victoria Tran, Wellness Director Michelle Adams, and resident #1. LPA Wesley requested a copy of the resident roster, staff roster and requested copies of specific documents.

Regarding allegation: Facility did not safeguard resident's mail package. During the interview with the Administrator she advised that she was not aware that resident #1 was expecting a package and they did not receive any packages addressed to resident #1 on 01/26/2022 or any other recent days. Wellness Direcor Michelle Adams also advised that the facility did not receive any packages delivered to the facility for resident #1. Resident #1 advised that did not receive the package that was ordered and contacted the mail carrier who
Continued on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
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 3
Control Number 28-AS-20220126164202
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: 05/04/2022
NARRATIVE
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advised that the package was delivered to the facility. LPA Wesley was provided a copy of the invoice/receipt and delivery confirmation. LPA Wesley and Administrator Tran walked to the Skilled Nursing Facility(SNF) that also shares the same address as the Residential Care Facility for the Elderly(RCFE), on the same lot and the check in point for screening and delivery of packages. The investigation revealed that the SNF could not locate the delivery log, package and the previous receptionist no longer works in the facility.


Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.


Exit interview conducted.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220126164202
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2022
Section Cited
CCR
87218(a)(2)
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Theft and Loss
A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value.
This requirement has not been met as evidence by: On 01/26/22, Amazon delivered
a package#112-03293623067463
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The Licensee/Administrator shall provide a refund to resident #1 in the amount of $20.94 by POC date 05/17/22 and send proof of corrections to CCLD/Attn Nicol Wesley.
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to the facility that was received in the reception area for resident #1 in which they never received the package. This can pose a potential health and safety risk for residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3