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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 07/01/2022
Date Signed: 07/01/2022 02:58:55 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
06/21/2022 and conducted by Evaluator Joe Katrdzhyan
COMPLAINT CONTROL NUMBER: 28-AS-20220621140044
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: 47DATE:
07/01/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Assistant Administrator / Janice Solis
Administrator / Victoria Tran		TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not address cockroaches in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Assistant Administrator / Janice Solis and was later joined by the Administrator / Victoria Tran who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of Staff did not address cockroaches in the facility .

During today's visit, LPA interviewed the Administrator, Staff members 1 through 4 (S1 - S4) and Residents 1 through 4 (R1 - R4). LPA toured the dining room (which is currently being used as the activities room) and random selection of resident rooms. LPA also toured room 69-A, which is being used a storage room. Copies of invoices from Orkin Pest Control were obtained and reviewed.

The investigation revealed the following;
Allegations: Staff did not address cockroaches in the facility. The details of this allegation states that the facility is infested with cockroaches.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
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 5
Control Number 28-AS-20220621140044
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: 07/01/2022
NARRATIVE
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Based on interviews conducted, LPA obtained statements which were consistent and corroborated with the allegation. Statements obtained confirmed observing cockroaches in facility hallways and in resident rooms. At 11:55am, LPA toured the dining room and observed dead cockroaches throughout the dining room area. At 12:02pm, LPA toured room 69-A and observed dead cockroaches in the living room area, bathroom floor, bathroom cabinet, and inside the bathtub. According to the Administrator, the facility has a contract through Orkin Pest Control which regularly services the facility (once a month) and sprays certain areas of the facility. The Administrator was unsure why there were dead cockroaches found in the dining room and in room 69-A.
Based on interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true.

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

An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220621140044
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: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not being met as evidenced by:
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Administrator will develop a plan with a licensed pest control company and provide a copy of the contract to CCL outlining a revised approach to eradicate the ongoing issue of cockroaches inside the facility. POC must be submitted to CCL by the POC due date.
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Statements obtained confirmed observing cockroaches in facility hallways and in resident rooms. At 11:55am, LPA toured the dining room and observed dead cockroaches throughout the dining room area. At 12:02am, LPA toured room 69-A and observed dead cockroaches in the living room area, bathroom floor, bathroom cabinet, and inside the bathtub.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/21/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220621140044

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: 47DATE:
07/01/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Assistant Administrator / Janice Solis
Administrator / Victoria Tran		TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not address rodent's in the facility.

Staff did not address flies in the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Assistant Administrator / Janice Solis and was later joined by the Administrator / Victoria Tran who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegations of Staff did not address rodent's in the facility and Staff did not address flies in the facility.

During today's visit, LPA interviewed the Administrator, Staff members 1 through 4 (S1 - S4) and Residents 1 through 4 (R1 - R4). LPA toured the dining room (which is currently being used as the activities room) and random selection of resident rooms. LPA also toured room 69-A, which is being used a storage room. Copies of invoices from Orkin Pest Control were obtained and reviewed.

The investigation revealed the following;
Allegations: Staff did not address rodent's in the facility. The details of this allegation states that the facility
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220621140044
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: 07/01/2022
NARRATIVE
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is infested with rodents.
Based on interviews conducted, the majority of the statements obtained were inconsistent and did not corroborated with the allegation. Staff and residents interviewed denied the facility having an infestation of rodents. Staff and residents denied observing rodents (rats) inside the facility. LPA reviewed the monthly invoice records from Orkin for period April 2022 - June 2022 and discovered that servicing is done for preventative measures at the facility by inspecting all areas, servicing all interior tin cats (kitchen, laundry and storage) and servicing all exterior bait stations. No indication was made on the invoice records of rodents being present inside the facility. Based on interviews conducted, LPA's observation and record reviews, there is insufficient evidence to support this allegation to be true.

Allegation: Staff did not address flies in the facility.
Based on interviews conducted, the majority of the statements obtained were inconsistent and did not corroborated with the allegation. Staff and residents interviewed denied the facility having an infestation of flies. During a walk through of the facility, LPA did not observe an infestation of flies inside the facility. LPA learned that once in a while resident rooms may have fruit flies due to residents leaving foods/fruits inside their rooms and forgetting to dispose them. Based on interviews conducted and LPA's observation, there is insufficient evidence to support this allegation to be true.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5