198601962-5-23-2022-28-AS-FFIS-CZ4RRK-20240102121509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 05/23/2022
Date Signed: 05/23/2022 04:23:22 PM

Unsubstantiated

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
05/06/2022 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220506112905

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:	01:30 PM
MET WITH:	Victoria Tran		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility had a fire.
Facility telephones are not working.
Facility lights are not operating properly.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced subsequent 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, interviewed Southern California Edison (SCE) Foreman, other parties, Administrator Victoria Tran, residents, staff and collateral visits at nearby homes.

Regarding allegations: Facility had a fire, Facility telephones are not working, Facility lights are not operating properly. LPA Wesley interviewed Administrator Victoria Tran who advised that on 05/05/22 around 3:35 pm there was an underground transformer that blew underground and also said that there was no fire inside of the facility electrical room. LPA Wesley interviewed Job Foreman Santiago from SCE who confirmed that there was an undergound circuit that caused and explosion due to a faulty transformer that had blown. SCE Foreman

Unsubstantiated

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-20220506112905

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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advised that the explosion(fire) caused a power outage and hundreds of neighbors and businesses were affected. Administrator Trans advised that the facility placed Back up lighting throughout the halls, and portable lights in residents rooms and also advised that there were no residents who required any insulin injections, or equipment. Administrator Tran also advised that the facility had emergency oxygen tanks delivered to the facility as a back up and that the underground electrical explosion that occurred outside of the facility premises did not affect the telephone lines. LPA Wesley interviewed staff and residents who confirmed that there was an electrical fire but it was not caused by a fire inside the facility electrical room, and the telephones were not affected. LPA Wesley and Administrator toured the facility and did not observed any indications that a fire occurred inside of the building.

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 allegations is unsubstantiated. No deficiencies were cited during todays visit. A copy of the licensing report was given during the exit Interview.

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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