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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 04/26/2021
Date Signed: 04/26/2021 03:46:55 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
10/03/2019 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20191003123617
FACILITY NAME:SOUTHLAND LIVINGFACILITY NUMBER:
198601962
ADMINISTRATOR:SOKOLOWSKI, MICHAELFACILITY TYPE:
740
ADDRESS:11701 STUDEBAKER ROADTELEPHONE:
(562) 406-7326
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:75CENSUS: 47DATE:
04/26/2021
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Victoria Tran, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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1. Resident sustained injuries from multiple falls while medicated.
2. Facility is administering medication for resident without proper authorization.
3. Staff mishandling resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan initiated a subsequent complaint investigation for the allegations 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 Victoria Tran, the facility administrator.

The investigation consisted of the following:
On 10/11/2019, LPA Juan Miramontes conducted the initial complaint visit and delivered the unsubstantiated findings. During the visit, LPA Miramontes received copies of the resident and staff rosters, reviewed facility record files for Resident #1-4 (R1 - R4), and obtained copies of the ID Sheet, Physician's Report, list of medications, nursing notes, and Special Incident Reports. LPA Miramontes also conducted interviews with Administrator Tran, Staff #1, and with R1, R3, and R4. R2 was not available during time of LPA's visit.
On 2/22/2021, LPA Chan re-interviewed the Administrator and requested for July through October 2019 MAR logs for R1. On 4/8/2021, LPA Chan interviewed additional 3 staff and 6 residents.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20191003123617
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: 04/26/2021
NARRATIVE
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The investigation revealed the following:
Regarding allegation - Resident sustained injuries from multiple falls while medicated. It was alleged that Resident #1's (R1) medications taken during 2019 were causing resident to fall. According to the Administrator, Resident #1 (R1) had a couple of falls that were documented back in 2019. The falls were also reported to the R1's son and the physician. Based on the special incident reports, on 7/30/2019, R1 fell and was sent to the hospital and was brought back to facility without any injuries noted. On 8/2/2019, R1 had a fall at approximately 3:45am which R1 was sent to the hospital due to complaining of pain. The Emergency Room physician recommended that the resident be admitted for observation, but R1 and R1's son did not want the resident to be admitted and returned to the facility without any injuries or fractures. On the same day at 10:35am, R1 had another fall which resident sustained a hip fracture and was admitted to the hospital. 2 of the 3 staff LPA Chan interviewed recalled R1 having multiple falls but showed no signs of injuries and reported R1 was medication compliant majority of the time. Per Administrator, R1's doctor indicated the medications R1 was taking at that time were appropriate. Although resident had multiple falls, there were no evidence that R1 medications were causing the falls. LPA also did not see any signs of neglect from the facility.

Regarding allegations - Facility is administering medication for resident without proper authorization and staff mishandling resident's medication. Administrator Tran indicated that she had spoken to R1's physician and questioned about the resident's medication since R1 was having multiple falls. The physician informed her that R1's medications were appropriate at that time. LPA Chan reviewed the physician's order and MAR log from July though October 2019 and medications appeared to match according to the physician's order. There were no indications that the Med Techs had mishandled R1's medications. 5 out of 6 residents that LPA Chan interviewed stated that the Med Tech brings their medications to them on time and takes them daily. The Medication Technicians also stated they would not distribute medication if not prescribed by the physician.

Based on additional documents and interviews conducted, it does not change the previous unsubstantiated findings for these allegations rendered on the initial visit. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

A telephonic exit interview was conducted with the Administrator Victoria Tran. A hard copy of this report was emailed for a signature and the appeal rights were also provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2