198601962-5-23-2022-28-AS-RORN-CNUM6E-20230208081946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 05/23/2022
Date Signed: 05/23/2022 04:18:50 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
05/13/2022 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220513084603

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: 47	DATE:	05/23/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Victoria Tran		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility is in disrepair

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 Wesley requested a copy of the resident roster, staff roster, facility sketch, interviewed Administrator Victoria Tran, other parties, and toured the facility physical plant.

Regarding allegation: Facility is in disrepair. LPA Wesley and Administrator Tran toured the physical plant and observed 3 laundry rooms that contained washers and dryers for the staff and resident to use, the washer in laundry room #1 contains missing knobs and other knobs on the washer that are not operable, and flooring that needs to be repaired. Laundry room #2 contained a lint build up on the walls and cords, and the panel for the controls to be loose. Laundry room #3 contained 2 unoperable dryers. LPA Wesley observed the roof to have patches/repair work that was completed on 12/20/2021 from the previous rain storm that caused a leak during
continued on LIC 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

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-20220513084603

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: 05/23/2022

NARRATIVE

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that time. The observation of the patches on a specific area on the roof(dining room area) does not indicate that the facility is in need of a new roof as the roof appears to be intact. During the interviews with residents and staff, it appears that there have not been any recent roof leaks. LPA Wesley and Administrator Tran toured the physical plant and did not observe there to be any mold on the interior and exterior areas of the facility that was toured during todays visit. LPA Wesley observed: wood pieces, toilets, iron gates, debris, old laundry equipment, inoperable work truck, wooden pallets on the side of the facility near the side parking adjacent from the school that was previously addressed during a case management inspection on 05/10/22.

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. Appeal rights were given.

Exit interview conducted.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220513084603

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: 05/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/22/2022 Section Cited CCR 87303	1 2 3 4 5 6 7	Maintenance and Operations 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 has not been met as evidence by: During todays visit, LPA	1 2 3 4 5 6 7	The Licensee/Administrator shall have items cleaned/replaced/repaired and/or removed by POC date 06/22/22 and send proof of corrections to CCLD/Attn Nicol Wesley.
	8 9 10 11 12 13 14	oberved there to be washers and dryers in need of repairing/replacing and 2 in operable dryers in laundry room #3. Flooring in laundry room #1 in need of replacing, and laundry room #2 in need of a thorough cleaning/dust removal which can pose a health and safety risk for residents in care.	8 9 10 11 12 13 14
	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.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC9099 (FAS) - (06/04)

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