198601962-12-21-2023-28-AS-FFIS-CZ4RRJ-20240102121509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:56:07 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 Ashley Calderon

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: 49	DATE:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Assistant Administrator Zachary Miller / Administrator Victoria Tran		TIME COMPLETED:	03:35 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) Ashley Calderon conducted an unannounced subsequent visit and upon arrival met with Housekeeper Guadalupe Sanchez and shortly after with Med-Tech/ Caregiver Abigial Reyes. Reyes paged Assistant Administrator Zachary Miller to assist with the visit. LPA met Assistant Administrator at 10:00am, LPA discussed the purpose of today's visit. At 11:15am Administrator Victoria Tran arrived to assist with the visit.

On 5/23/22, LPA Wesley interviewed Administrator and Forman from Southern California Edison and conducted a tour of the facility alongside with Administrator.

Today's investigation conducted on 12/21/23 consisted of the following: LPA Calderon collected a staff and resident roster for 2022 and Special Incident Report (SIR) dated 5/6/22. LPA alongside with Staff #1 and Assistant Administrator observed the area of the city explosion, observed Emergency Disaster Plane in Place, observed emergency disaster kit in medication room including flight light(s). LPA conducted interviews with Administrator via telephonically, Staff #1- Staff #4 (S1-S4) and Resident #1- Resident#5 (R1-R5). (Continuation on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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: 12/21/2023

NARRATIVE

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Regarding allegations: Facility had a fire. The following was revealed: LPA Wesley and Administrator on 5/23/22, toured the facility and did not observed any indications that a fire occurred inside of the building.
LPA Wesley interview conducted with Foreman from Southern California Edison (SCE), confirmed that there was an underground circuit that caused an explosion due to a faulty transformer that had blown. SCE Foreman advised LPA Wesley that the explosion (fire) caused a power outage and hundreds of neighbors and businesses were affected. Interviews conducted by LPA Calderon with Administrator and S1-S4, and interviewed R1-R5, revealed explosion/ transformer blow out occurred on streets and not on the facility premises. LPA Calderon was informed that the Assisted Living facility lost power due to city transformer blow out. (5) out of (5) interviews conducted with residents who were present in 2022 informed LPA that facility did not have a fire and what occurred was a transform blow out in the city. On 12/21/23, LPA Calderon observed explosion area, based on observation and interviews explosion occurred on the streets of City of Norwalk and did not occur on facility perimeter.

Regarding allegation: Facility telephones are not working. The following was revealed: Administrator Tran advised LPA Wesley on 5/23/22, that there was an underground electrical explosion occurred outside of the facility premises and did not affect the telephone lines. LPA Calderon conducted interviews with Administrator and S1-S4 revealed facility had working land lines and facility had power back up. (5) out of (5) interviews LPA Calderon conducted with residents revealed residents were unable to collaborate to this allegation due to residents having their own personal cell phones.

(Continuation 9099-C)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 12/21/2023

NARRATIVE

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Regarding allegation: Facility lights are not operating properly. The following was revealed: (4) out of (5) staff interviews conducted by LPA Calderon revealed facility used electricity power and generator from the Southland Skilled Nursing Facility (SNF) side to provide power and lighting in Assisted Living facility hallways. Based on interviews with (5) staff and (5) residents, there was a facility power outage due to a city transformer explosion and resident's had emergency back up lighting. LPA Calderon was informed that the SNF side were not affected by the power outage due to being on different transformer. Investigation revealed that lights were not working property due to city issue/ incident that occurred near facility. Administrator Tran advised LPA Wesley on 5/23/22, that the facility placed back up lighting throughout the hallways, portable lights in residents rooms to those who needed it. LPA observed Emergency exit lights thought the facility, emergency oxygen tanks, disaster kit in medication and flashlight(s. LPA Calderon reviewed SIR regarding city transformer incident, that was reported to Licensing in a timely manner during time of incident. SIR states facility provided flashlights, provided resident's choice to be placed else where if needed, had emergency oxygen tanks and city was aware of incident and city was working on fixing the program.

Investigation revealed facility took measures in to place to provide resident's with a safe and healthy environment during time of incident occurring outside near facility that was a city issue that affected residents, city problem was out of the control of the facility. LPA Calderon observed Emergency Disaster Plan in place during time of visit.

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

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