198601962-3-14-2021-28-AS-MVAO-BZLQFJ-20210330120800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 03/01/2021
Date Signed: 03/14/2021 04:36:15 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
12/22/2020 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201222172424

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:	12:00 PM
MET WITH:	Victoria Tran		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Lack of supervision resulting in resident suffering a fall.

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 by 12/24/20. LPA also interviewed the Administrator Victoria Tran, residents, and observed photos.

Investigation revealed the following: Resident #2 observed that resident #1 had fallen out of their electric wheelchair into the water drainage ditch located towards the back corner of the facility grounds. Resident #2 said that they also observed that Resident #1 was also trying to transport a television in the wheelchair and
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-20201222172424

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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believes that's how the wheelchair tilted over. Resident #2 said that other residents often warned resident #1 about entering into that area because there is no pavement, sidewalks and it is off limits to residents and they said resident #1 tells them off and continues to enter into the area. During the interview with resident #1 who is able to leave the facility unassisted said they don't remember the exact date of the incident due to their current medical condition but did admit they were aware that the area in which they had fallen is not accessible to residents and they are not supposed to enter into the area but the facility just does that to pick on residents who are disabled. Administrator Victoria Tran said that on 07/18/2019, at approximately 11:30 am resident #2 asked if she could go provide assistance to resident #1 who had fallen out of their scooter into the ditch in the grass area. Administrator Tran assisted resident #1 and asked why were they in an area that is off limits to residents, and also explained that the grounds are not leveled or paved. The investigation revealed that resident #1 did not fall due to Lack of supervision.

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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