198601962-8-12-2021-28-AS-LHIS-C7PST4-20211011140852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 08/12/2021
Date Signed: 08/12/2021 04:59:02 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
02/16/2021 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210216105922

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: 44	DATE:	08/12/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Victoria Tran		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not obtain resident's medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced subsequent 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: On 02/18/21 LPA Wesley conducted a telphonic interview and requested copies of: staff roster, resident roster, medication/prescription list, current physicians report, and facility staff notes for resident #1 to be emailed/faxed by 02/19/21. LPA also interviewed the Wellness director Michelle Adams regarding the above mentioned allegation.

Regarding allegation: Facility did not obtain resident's medication. During the investigation it was discovered that on 01/20/2021 resident #1 was re-admitted to the Southland Living upon receiving treatment from the Skilled Nursing Facility(SNF). Upon discharge from there was a list of medication for resident #1 that did not include any prescriptions for any type of relaxation medication. It has also been determined that resident #1 was Continued on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

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-20210216105922

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: 08/12/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

receiving care from the SNF and Southland Living did not receive any additional orders from the doctor other than what was prescribed during resident #1's return to the facility per the doctors order on 01/20/21. During the interview with Wellness Director Michelle Adams, LPA was advised that resident #1's family member inquired about a medication for resident #1 and could not remember the name, and was informed by the Wellness Director that the currently Physician's orders did not include any medication prescription for relaxation. LPA Wesley reviewed resident #1's facility file which included but not limited to the observation of: Physician's reports, Medication profile(list of medication) dated 01/20/21 per the doctor's order, as well as the residents Medication Administrator Record(MAR) and there is not sufficient evidence to support the allegation facility did not obtain resident's medication.

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.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2