198601962-8-6-2024-28-AS-RORN-D7XTWT-20240808150603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 08/06/2024
Date Signed: 08/06/2024 09:56:00 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
07/23/2024 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240723101048

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: 52	DATE:	08/06/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Zach Miller - Assistant Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Due to lack of supervision, resident fell sustaining an injury.
Staff did not notify authorized representative of incident.
Staff did not seek timely medical care for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera made an unannounced subsequent visit to deliver findings on the above allegations. LPA met with Assistant Administrator Zach Miller and explained the reason for the visit.
- The investigation consisted of the following: During initial visit dated 7/23/24 LPA obtained copies of Resident Roster, Face Sheet, Hospitalization Census List (from Skilled Nursing Facility (SNF) – Southland Care Center - that is separate from Assisted Living) and interviewed both Administrator at Southland Living and Administrator at Southland Care Center (SNF). Based on interviews conducted and review of rosters and review of Resident #1’s (R1) admission record, it was determined that R1 resides at Southland Care Center not Southland Living. It was also determined that R1 has never resided at Southland Living.
- Based on the information gathered during this visit, the allegations are deemed UNFOUNDED. A finding of UNFOUNDED means that the allegation is either false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and a copy of this report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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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