198601962-8-12-2021-28-AS-LHIS-C7PSXF-20211011141551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 08/12/2021
Date Signed: 08/12/2021 05:00:13 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
08/04/2021 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210804160150

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:	01:00 PM
MET WITH:	Victoria Tran		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced initial complaint visit and met with Administrator Victoria Tran, Wellness Director Michelle Adams to discuss the purpose for todays visit. During the visit, Maintenance staff Ben Mota arrived and joined the visit.

The investigation consisted of the following: LPA toured the facility including the dining area, and resident hallway, interviewed residents, interviewed staff and requested copies of specific documents.

Regarding allegation: Facility is in disrepair. LPA toured the facility including the common areas/hallways, bathrooms, dining room, observed all pictures on the walls, ceilings, as well as the electrical outlets and did not observe/discover any items that were in disrepair. During the interview with Administrator Victoria Tran, she advised that on 08/03/2021 in the evening, staff reported that there was a water leak coming from the ceiling in one of the common hallways next to the conference. Administrator Tran said there was some water on the floor
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)

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Control Number 28-AS-20210804160150

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

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and staff blocked off both sides of the hallway so that no one would enter into the area. Administrator Tran advised that the Maintenance staff Ben Mota was called who had just exited the facility, came back and repaired the pipe. Administrator advised that the repair was completed within two hours and she completed a SIR(unusual incident report) to the department. LPA interviewed Maintenance staff Mota who informed the LPA that he shut the water down, fixed the pipe, cleaned the walls and floors. Staff Mota said the job took him less than 2 hours to complete and the leak was caused due to a heating coil(circulation stopped) that was between the pipes. Mota also advised that the facility is not in disrepair because as soon as something occurs, they repair it right away. Mota said he has been working in the facility for eighteen years. LPA interviewed a random selection of residents who said the facility is not in disrepair and did not know there was a leak in the hallway. Other residents were interviewed and said they were aware of the leak in the ceiling and it was repaired right away and also said the facility is not in disrepair.

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)

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