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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 03/09/2021
Date Signed: 07/27/2021 06:28:51 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
10/05/2020 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201005101805
FACILITY NAME:SOUTHLAND LIVINGFACILITY NUMBER:
198601962
ADMINISTRATOR:TRAN, VICTORIAFACILITY TYPE:
740
ADDRESS:11701 STUDEBAKER ROADTELEPHONE:
(562) 406-7326
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:75CENSUS: 44DATE:
03/09/2021
UNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Victoria Tran TIME COMPLETED:
10:08 AM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner.
Staff do not meet resident's grooming needs.
Staff do not treat resident with dignity or respect.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Victoria Tran.

The investigation consisted of the following: On 10/12/20, LPA Wesley conducted a telephonic interview and requested copy of: staff roster, resident roster, Activities calendar, and bathing/grooming schedule for the month of September 2020, and special incident reports. LPA also interviewed the Administrator, Staff(S1-S3), and Residents(R1-R5).

The investigation revealed the following: regarding allegation: Staff did not seek medical attention for resident in a timely manner. During the interview with R1, LPA was informed that staff did not seek medical attention for them until 5 days later. R1 said they became ill with an infections but couldn't not confirm the date they became Continued on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
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 6
Control Number 28-AS-20201005101805
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: 03/09/2021
NARRATIVE
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ill and do not recall which staff they asked to seek medical attention for them. During the interview with the Administrator Victoria Tran, she advised that on 09/27/20 she and some staff observed R1 to be delusional, screaming and yelling at staff and acting like they were confused. Administrator said when she noticed that R1 lit a cigarette inside the facility and asked them to put it out(she knew something was wrong because although R1 is non compliant they never lit a cigarette inside the facility). Administrator advised that R1 refused to put the cigarette out, began yelling and cussing and at that time staff also observed there to be an onset of slurred speech. Staff immediately called 911 and R1 was saying "I'm okay," when the paramedics and ambulance arrived R1 was transported to the Hospital Emergency Room, where they were admitted and treated for a medical condition. During the interviews with the Administrator, and staff( S1-S3), they indicated they always seek medical attention for all residents in a timely manner. During the interviews with Residents(R2-R5), they confirmed that they received medical attention in a timely manner if they were in need. LPA Wesley observed 2 Unusual Incident Reports(UIR/SIR) dated 09/28/2020 for R1.
Regarding allegation: Staff do not meet resident's grooming needs and Staff do not treat resident with dignity or respect . R1 advised that they facility staff does not trim their hair or cut their nails and when they ask for staff to assist them, they are rude and does not assist them. R1 did not have any concerns regarding showering/hygiene. LPA Wesley observed the nail care log and care reference log for the month of September 2020. During the interview with Administrator Tran, she advised that during the pandemic, the facility has been following the stay at home order and department of public health guidelines and have provided nail care and hair grooming for the residents who may wish to participate by staff who are also nurses. The Administrator denied being rude to the residents including R1 or declining any services to them and have not observed any staff acting rude or declining services to any of the residents. Administrator also said that R1 receives services, but sometimes the resident refuses services so they can hurry and leave the facility to go into the community, disregarding the stay at home order and upon their return to the facility, R1 demands to receive the services at the times in which the staff is no longer available. During the interview with S1, they informed me that they schedule appointment times to provide nail care service for the residents and also make attempts to locate the residents so they wont missed their appointments. S1 advised that R1 returned to the facility and demands for staff to provide the services and begins yelling and cussing. S1 denied being rude to R1 and said they have never witnessed the Administrator or any other staff act rude to R1 or any residents in care. S1 said they never denied to provide service to R1 and said when its their turn for service, they are always out of the facility and sometimes they decline the services telling staff to "F" word out of my room!"

Continued on LIC 9099(Page 3).
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
10/05/2020 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201005101805

FACILITY NAME:SOUTHLAND LIVINGFACILITY NUMBER:
198601962
ADMINISTRATOR:TRAN, VICTORIAFACILITY TYPE:
740
ADDRESS:11701 STUDEBAKER ROADTELEPHONE:
(562) 406-7326
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:75CENSUS: 44DATE:
03/09/2021
UNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Victoria Tran TIME COMPLETED:
10:08 AM
ALLEGATION(S):
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Staff did not safeguard resident's personal items.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley initiated a complaint investigation for the allegation 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 Administrator Victoria Tran.

The investigation consisted of the following: On 10/12/20, LPA Wesley conducted a telephonic interview and requested copy of: staff roster, resident roster, Activities calendar, and bathing/grooming schedule for the month of September 2020, and special incident reports. LPA also interviewed the Administrator, Staff(S1-S3), and Residents(R1-R5).
The investigation revealed the following: regarding allegation: Staff did not safeguard resident's personal items. During the interview with R1 they indicated that the staff lost their cellphone while they were in the hospital in September 2020, and never replaced it. R1 said they asked Administrator Victoria Tran to replace their cell phone and she never did. LPA Wesley spoke to Administrator Victoria Tran who advised that staff placed the
Continued on LIC 9099A(C) Page 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20201005101805
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: 03/09/2021
NARRATIVE
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cellphone with R1 belongs while they were being transported to the hospital. The Administrator was asked to replace R1 phone sever times as R1 has been without their phone for several months. In late January 2021 when the Administrator finally decided to replace R1's phone, it was communicated that R1 did not want to provide their personal information to the staff so they could replace the phone. LPA Wesley spoke to R1 and ask them to provide the information so they could receive another phone and R1 said they provided the box and charger to the receptionist months ago and believed they were playing games. The investigation revealed that there is sufficient evidence to support the allegation: staff did not safeguard resident's personal items.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Administrator Victoria Tran, and a hard copy was provided via email to obtain a signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20201005101805
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2021
Section Cited
CCR
87218(a)(2)
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Theft and Loss. A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed current value and shall be presumed to have made reasonable efforts to
safeguard resident property if there is clear
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The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. The licensee shall provide a written plan of action informing the Licensing agency the steps that facility will take to assure that the theft and lost policies are adhered to by POC date 03/24/21.
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and convincing evidence of efforts to This evidence has not been met as required by: LPA Wesley requested the Administrator to replace R1s cellphone several times that was lost while under the facility care in 09/2020 as resident was being transported from the facility to the hospital. The phone was not replaced until 02/2021.
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**R1's cellphone and accessories were replaced in February 2021.***
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 28-AS-20201005101805
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: 03/09/2021
NARRATIVE
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R1-R5 were interviewed and said their grooming and hygiene needs are being met and that staff has never been rude to them and they have not witnessed staff being rude to any residents. R2 informed the LPA that often times, they have witnessed R1 cuss out S1 when they would try to assist them with nail care and grooming services, and they feel bad that the staff has to receive such abuse.


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 allegation is unsubstantiated. A telephonic exit interview was conducted with Administrator Victoria Tran, and a hard copy was provided via email to obtain signature.

There are no citations issued, exit interview conducted.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6