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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 08/20/2021
Date Signed: 08/20/2021 05:29:03 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
08/12/2021 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210812140900
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:
08/20/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Victoria Tran TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff member handled resident in a rough manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced initial complaint visit and met with Administrator Victoria Tran, and Wellness Director Michelle Adams to discuss the purpose for todays visit.

The investigation consisted of the following: LPA Wesley requested a copy of the staff roster, resident roster and specific documents. LPA interviewed Administrator, staff and residents. LPA Wesley attempted to interview staff #1 and was not successful.

Regarding allegation: Staff member handled resident in a rough manner. The investigation revealed that staff #1 appeared to handle the resident #1 and resident #2 a little rough while providing assistance with elements of daily living. Staff were interviewed and there was one staff who requested assistance with a resident transfer, and they advised that staff #1 handled a resident a little rough too quickly and the resident was not eased into their seat. During the interviews with staff, it was revealed that staff #1 was moving a little too fast when handling Continued on LIC 9099C.
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: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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 4
Control Number 28-AS-20210812140900
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: 08/20/2021
NARRATIVE
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providing care for residents. There was also another resident who complained when staff #1 entered into their room to provide assistance with incontinence care. During the interview with Administrator, they advised that they were not aware that staff #1 was handling residents in a rough manner until they received a complaint from resident #1 on 07/31/21, and at that time an internal investigation was conducted and staff #1 was suspended from work pending the outcome of the investigation. The Administrator did not observe there to be any physical injury or bruising. The Administrator crossed reported to Community Care Licensing Division(CCLD), Ombudsman(LTCO), and Adult Protective Services(APS). On 08/06/2021 staff #1 was reprimanded and placed on a performance plan and at that time staff #1 resigned. LPA attempted to interview staff #1 but was not successful as they no longer work at the facility.

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.


Exit interview conducted.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
08/12/2021 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210812140900

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:
08/20/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Victoria Tran TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff member had an altercation with resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced initial complaint visit and met with Administrator Victoria Tran, and Wellness Director Michelle Adams to discuss the purpose for todays visit.

The investigation consisted of the following: LPA Wesley requested a copy of the staff roster, resident roster and specific documents. LPA interviewed Administrator, staff and residents. LPA Wesley attempted to interview staff #1 and was not successful.

Regarding allegation: Staff member had an altercation with resident. During the interview with resident #1 it was communicated that there was no altercation with staff #1 regarding the incident on 07/31/21. Resident #1 said they just informed Administrator Tran and Wellness Director Adams so they could discuss it with staff #1. 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.
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: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20210812140900
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: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in All Facilities
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating,
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Administrator will provide Personal rights training to all staff including but not limited to the handling and transfering of resdients who requires care and supervision. Provide the in service training log and sign in sheet to LPA Wesley by POC due date 09/03/2021.
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sleeping, or elimination.
This requirement was not met as evidenced by: On 07/31/21 staff #1 handled resident #1 in a rough manner, which can poses a potential health risk to residents in care.
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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: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4