198601964-11-3-2023-11-AS-MVAO-CXMURT-20231116144917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601964
Report Date: 11/01/2023
Date Signed: 11/03/2023 08:23:04 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2023 and conducted by Evaluator Lizeth Villegas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230209081915

FACILITY NAME:	HAZELBROOK HOME		FACILITY NUMBER:	198601964
ADMINISTRATOR:	PEARL M LAMB		FACILITY TYPE:	735
ADDRESS:	4857 HAZELBROOK AVENUE		TELEPHONE:	(562) 452-7034
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	3	CENSUS: 3	DATE:	11/01/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator Maria Cristina Serafico		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Licensee does not meet residents' dietary needs.
Licensee does not meet resident's incontinence needs.
Facility bathroom not equipped with non-stick mats.
Staff do not distribute resident's medication as prescribed.
Licensee does not store toxins locked and inaccessible to residents.
Licensee does not provide residents with activities.
Facility bathroom not equipped with privacy curtain.
Licensee does not accommodate resident with adequate clothing.

INVESTIGATION FINDINGS:

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On 11/01/23 at 9:20 am Licensing program analyst (LPA) Lizeth Villegas conducted an initial complaint investigation and render findings regarding the above allegation(s). LPA met with Administrator
Maria Cristina Serafico (A1) as the purpose of today’s visit was explained.

During today's visit LPA obtained copies of staff and resident rosters,menus for the months of October 2023-March 2024, activity calendars for September, October, and November 2023, Bowel movement (BM) forms, urine output logs, and medication administration records for the month of September and October 2023. LPA toured the facility and interviewed Administrator (A1), staff #1-2 (S1-S2) and residents #1-3 (R1-R3).

The investigation revealed the following: Allegation: Licensee does not meet residents'ietary needs.
On 11/01/23 LPA conducted tour of kitchen and inspected pantry, LPA observed food supply to be fully stocked. On 11/01/23 LPA interviewed A1 about the above allegation, A1 denied the allegation and

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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 3

Control Number 11-AS-20230209081915

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAZELBROOK HOME	FACILITY NUMBER: 198601964
	VISIT DATE: 11/01/2023

NARRATIVE

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reported that groceries are bought weekly. On 11/01/23 LPA interviewed S1-S2 about the allegation above, 2 of 2 staff interviewed denied the allegation above and reported that groceries are bought weekly. On 11/01/23 LPA attempted to interview R1-R3 but R1-R3 were unable to provide a response. LPA observed refrigerator and pantry to be fully stocked.

The investigation revealed the following: Allegation: Licensee does not meet resident's incontinence needs

On 11/01/23 LPA interviewed A1 about the above allegation, A1 denied the allegation above. A1 reported residents are checked regularly and staff does not wait for the 2 hour mark to meet incontinence needs. On 11/01/23 LPA interviewed S1-S2 about the allegation above, 2 of 2 staff interviewed denied the above. Per S1-S2 residents are checked every 30 minutes and are changed if needed. On 11/01/23 LPA attempted to interview R1-R3 but R1-R3 were unable to provide a response. On 11/01/23 LPA conducted review of BM form and urine output log and did not observe any discrepancies, LPA also observed incontinence supplies to be fully stocked at the time of visit.

The investigation revealed the following: Allegation: Facility bathroom not equipped with non-stick mats.
LPA conducted a tour of the 2 facility restrooms and observed non-stick mats inside the showers.

The investigation revealed the following: Allegation: Staff do not distribute resident's medication as prescribed.
On 11/01/23 LPA interviewed A1 about the above allegation, A1 denied the allegation above. Per A1 physicians orders are always followed in order to avoid a medication error. On 11/01/23 LPA interviewed S1-S2 about the allegation above, 2 of 2 staff interviewed denied the above. Per S1-S2, medications are only held per physicians orders if the BP is below 110, vitals are taken second a time and if BP is above 110 medication is provided. On 11/01/23 LPA attempted to interview R1-R3 but R1-R3 were unable to provide a response. On 11/01/23 LPA conducted review of medication administration records and did not observe any discrepancies.

The investigation revealed the following: Allegation: Licensee does not store toxins locked and inaccessible to residents.
On 11/01/23 LPA conducted a tour of the facility and observed all toxins to be locked and inaccessible to

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230209081915

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAZELBROOK HOME	FACILITY NUMBER: 198601964
	VISIT DATE: 11/01/2023

NARRATIVE

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residents.

The investigation revealed the following: Allegation: Licensee does not provide residents with activities.

On 11/01/23 LPA conducted a tour of the facility and observed a variety of activities accessible to residents.
On 11/01/23 LPA interviewed A1 about the above allegation, A1 denied the allegation above stating that
both indoor and outdoor activities are provided daily. On 11/01/23 LPA interviewed S1-S2 about the allegation above, 2 of 2 staff interviewed denied the above. Per S1-S2 there are activities available every day, activities are scheduled to accommodate residents preferences, request and likes. On 11/01/23 LPA attempted to interview R1-R3 but R1-R3 were unable to provide a response. LPA observed activity calendars for September- November 2023 and confirmed activities are provided.

The investigation revealed the following: Allegation: Facility bathroom not equipped with privacy curtain.

On 11/01/23 LPA interviewed A1 about the allegation above, A1 denied the allegation and stated its th residents right to have privacy. On 11/01/23 LPA interviewed S1-S2 about the allegation above, 2 of 2 staff interviewed denied the above. Per S1-S2 privacy curtain is only removed when being washed. On 11/01/23 LPA attempted to interview R1-R3 but R1-R3 were unable to provide a response. On 11/01/23 LPA conducted a tour of the 2 facility restrooms and observed privacy curtain in place.

The investigation revealed the following: Allegation: Licensee does not accommodate resident with adequate clothing.

On 11/01/23 LPA interviewed S1-S2 about the allegation above, 2 of 2 staff interviewed denied the above. Per S1-S2 conservators will bring clothing to the facility or administrator will assist with shopping trips when requested. On 11/01/23 LPA attempted to interview R1-R3 but R1-R3 were unable to provide a response.

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.

Exit interview conducted with Administrator Maria Cristina Serafico, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

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