198601962-2-1-2024-28-AS-RORN-D27VR5-20240206153922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 02/01/2024
Date Signed: 02/01/2024 12:18:33 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
04/03/2023 and conducted by Evaluator Valeria Maldonado

COMPLAINT CONTROL NUMBER: 28-AS-20230403135945

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: 53	DATE:	02/01/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Victoria Tran- Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff leave resident in bed for prolonged periods of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced susequent visit to the facility for the purpose of continuing the investigation regarding the above-mentioned allegeation. LPA Maldonado met with Wellness Director, Michelle Adams, and explained the purpose for the visit. Administrator, Victoria Tran, arrived shortly after to assist with the visit.
On 4/11/23, LPA Ashley Calderon conducted an initial visit and met with Wellness Director, Michelle Adams, and Administrator, Victoria Tran. The visit consisted of the following: LPA Calderon obtained a copy of the resident/staff roster, Resident #1 (R1) Admission's Agreement, Physician's Report, Appraisal Needs/Service-Care Plan- 603A/Level of Care Plan, Progress Notes, Hospice Care Plan, and Special Incident Reports. Rooms 4,11,21,23,32,47, and dining/activity room were toured with Administrator and interviews were conducted with Administrator Victoria Tran, Staff #1-#4 (S1-S4) and Residents #1-#5 (R1-R5). Telephone interviews were also conducted with R1's Guardian/Conservator and Hospice Care company.
During today's visit, LPA Maldonado obtained additional progress notes for R1 regarding refusal/unwillingness to cooperate with transfers out of bed.
(Report continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

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-20230403135945

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: 02/01/2024

NARRATIVE

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The investigation revealed the following:
Regarding allegation: Staff leave resident in bed for prolonged periods of time.
It is alleged that R1 reported to have been left in bed for 3 weeks and had not been outside. Per interviews conducted with staff, (5) of (5) staff denied the allegation and stated R1 required a (2) to (4) person assist when transferring, but was not willing to cooperate with staff during the transfers and would throw self back during the assists, making it more difficult to transfer. Staff stated they had no issues with transferring other residents that required the assistance. Per resident interviews, (4) of (5) residents could not corroborate the allegation. After review of R1's Care Plan, it was noted that R1 requires a (2) to (4) person assist to transfer. Per R1's Physician's Report, R1 is non-ambulatory and is unable to transfer out of bed on their own. R1's Appraisal/Needs and Services Plan indicates R1 requires maximum assistance with mobility and transferring in and out of bed/chair. Per Hospice Notes and facility Progress Notes, it was discovered that on 2/05/23, R1 was assisted by facility staff with standing. On 2/10/23, R1 was assisted by (2) facility staff with transferring to chair, but was throwing self back even while being assisted. On 2/22/23, R1 refused to be assisted by facility staff with care. On 03/02/23, assistance with transfer was provided by (3) staff, and R1's guardian was later notified of R1's refusal to care despite being provided with a (2) person assist. On 4/25/23, while R1 was moving out of the facility, R1 had a (4) person assist, and although R1 was able to get up, R1 then refused to be assisted into the car that was picking R1 up. Per interview conducted with R1's hospice agency, and per hospice record review, there was no written order for use of a hoyer lift to assist with R1's transfers, although the hospice care physician only made a verbal recommendation that a hoyer lift could help. The facility is not required to have a hoyer lift, and per interview with Administrator, none of the facility staff are trained to use a hoyer lift due to the facility not using or owning one. There are no residents in the facility who require assistance with transfer by hoyer lift.

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

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

LIC9099 (FAS) - (06/04)

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