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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601965
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:29:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20231004120545
FACILITY NAME:LURAY HOMEFACILITY NUMBER:
198601965
ADMINISTRATOR:SHIRENA L MUHAMMADFACILITY TYPE:
735
ADDRESS:930 E. LURAY STREETTELEPHONE:
(562) 612-3752
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:3CENSUS: 2DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:STAFF BRANDON HAYESTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
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7
8
9
Facility did not ensure that resident received prescribed medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
THIS REPORT SUPERSEDES THE REPORT DATED 10/12/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: SUBSTANTIATED
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Luray Home facility on 10/12/2023 and was greeted by Licensee Voneric Johnson (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit on 10/12/2023. LPA Calderon initiated an investigation into the above-mentioned allegations and conducted an in-person interview with Licensee Voneric Johnson (A1).

The investigation consisted of the following: LPA Calderon interviewed Administrator (A1), staff (S1), and client (C1-C3). These interviews were conducted on 10/12/2023. LPA Calderon obtain and reviewed the following: Physician’s report (dated 09/21/2023), Medical Administration Record (dated 10/4/23 to 10/08/23), Incident report (dated 10/01/23,10/04/23), Medication orders (dated 10/04/2023), Hospital discharge records (dated 10/03/2023), LVN nurse notes (dated 10/01/2023, 10/04/2023), Restricted Health Condition Care Plan (RHCP) (dated 10/06/2023) for C1. Staff training (dated 10/06/2023)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 11-AS-20231004120545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LURAY HOME
FACILITY NUMBER: 198601965
VISIT DATE: 02/22/2024
NARRATIVE
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The investigation revealed the following:

Regarding Allegation #1: Facility did not ensure that resident received prescribed medications.

This complaint alleged that staff did not have prescribed insulin or metformin for C1 use. On 10/12/2023 LPA Calderon obtained and reviewed the physician order (dated 09/23/2023 and 10/04/2023). The prescription order indicated taking one 500 mg Metformin tablet by mouth twice a day with morning and evening meals. Medication Administration Record (MAR) for C1 noted that Metformin was given to C1 from 10/01/2023 to 10/08/2023. LPA Calderon interviewed with A1. A1 stated that C1 was a client from 09/28/2023 to 10/08/2023. A1 reported that C1 did not arrive at the facility with insulin or Metformin. A1 claimed that staff ordered Metformin for C1 on 09/23/2023 and 10/04/2023. LPA Interviewed with S1. S1 stated that S1 reviewed C1’s medical records and Metformin was ordered on 09/23/2023 and based on the (MAR), Metformin was given to C1 from 10/01/2023 to 10/08/2023. LPA Calderon could not interview C1 as C1 moved out of the facility on 10/08/2023 and did not have forwarding contact information. C2 is non-verbal so no interview was available. An interview with C3 reported that staff has never run out of C3’s medications and has never missed giving C3 medications timely. Based on the information gathered, C1 who was admitted on 09/28/23 was not assisted with prescription medications until 10/01/23. C1 did not have the required Metformin and insulin for 09/28/23 through 9/30/23. Therefore, there is sufficient evidence to support this allegation mentioned above.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiency has been observed and citations issued (ref LIC9099D).



An exit interview was conducted and copy of the Complaint Report was provided to the Licensee Voneric Johnson (A1)
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 11-AS-20231004120545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LURAY HOME
FACILITY NUMBER: 198601965
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2024
Section Cited
CCR
80092.1(f)(2)(g)
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80092.1 General Requirements for Restricted Health Conditions (f) Prior to admission of a client ..(2) Ensure that facility staff who ...(g) All new facility staff who will participate...This requirement has not been met as evidenced by:
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Licensee will provide medication training to staff and email LPA Calderon copies of the training.
8
9
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14
Based on interview, observation, and record review the licensee failed to ensure that the clients Metformin medications order was made prior to client entering into the facility which posed a potential health risk to clients in care.
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9
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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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20231004120545

FACILITY NAME:LURAY HOMEFACILITY NUMBER:
198601965
ADMINISTRATOR:SHIRENA L MUHAMMADFACILITY TYPE:
735
ADDRESS:930 E. LURAY STREETTELEPHONE:
(562) 612-3752
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:3CENSUS: 2DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:STAFF BRANDON HAYESTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not following resident's dietary plan.
Facility is not properly training staff
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
THIS REPORT SUPERSEDES THE REPORT DATED 10/12/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: UNSUBSTANTIATED
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Luray Home facility on 10/12/2023 and was greeted by Licensee Voneric Johnson (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit on 10/12/2023. LPA Calderon initiated an investigation into the above-mentioned allegations and conducted an in-person interview with Licensee Voneric Johnson (A1).

The investigation consisted of the following: LPA Calderon interviewed Administrator (A1), staff (S1), and client (C1-C3). These interviews were conducted on 10/12/2023. LPA Calderon obtain and reviewed the following: Physician’s report (dated 09/21/2023), Medical Administration Record (dated 10/4/23 to 10/08/23), Incident report (dated 10/01/23,10/04/23), Medication orders (dated 10/04/2023), Hospital discharge records (dated 10/03/2023), LVN nurse notes (dated 10/01/2023, 10/04/2023), Restricted Health Condition Care Plan (RHCP) (dated 10/06/2023) for C1. Staff training (dated 10/06/2023)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20231004120545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LURAY HOME
FACILITY NUMBER: 198601965
VISIT DATE: 02/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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21
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32
The investigation revealed the following:

Regarding Allegation #1: Facility is not following resident’s dietary plan.

This complaint alleged that staff did not follow the R1 diabetic meal plan by serving R1 cereal. On 10/12/2023 LPA Calderon obtained and reviewed the physician report (dated 09/21/2023) The physician report states C1 has type 2 diabetes and a diabetic diet is suggested. LPA Calderon interviewed with A1. A1 stated that C1 is conserved and that C1's mother advised staff that C1 only likes cereal in the morning and at night and to serve a meal for lunch. A1 stated that there was no diabetic meal plan for C1, however, a review of records indicated that C1 had a Comprehensive Daily Nursing Evaluation for nutrition (dated 10/04/23). The Nursing Evaluation (dated 10/4/23 – 10/07/23) listed C1 as a diabetic diet and the nutrition health monitoring log maintained for C1 presented with a diet that includes carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk suited for a diabetic diet.


LPA Calderon interviewed with S1. S1 stated that S1 reviewed medical records for C1 and noted that C1 was diabetic. S1 spoke to C1's conservator who advised S1 that C1 only would eat cereal in the morning and at night. S1 states that staff called C1's doctor's office on 09/26/23 and 09/27/23 to have the physician order a diabetic meal plan for C1 but there was not enough time and C1 moved out on 10/08/2023. LPA Calderon could not interview C1 as C1 moved out of the facility on 10/08/2023 and C2 is non-verbal. LPA Calderon interviewed with C3. C3 states that C3 is not diabetic, and that staff serves 3 meals per day. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20231004120545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LURAY HOME
FACILITY NUMBER: 198601965
VISIT DATE: 02/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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18
19
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Regarding Allegation #2: Facility is not properly training staff.

This complaint alleged that staff are not given proper training to care for residents. On 10/12/2023 LPA Calderon obtained and reviewed the staff training (dated 10/06/2023). The training topic is” diabetes”, three staff took the training. LPA Calderon interviewed with A1. A1 stated that C1 was the first diabetic client for the facility. A1 stated that S1 provided training to staff that would care for C1 while C1 was at the facility and then S1 would follow up on additional training for staff that were not working at the time of training. LPA Calderon interviewed with S1. S1 states that S1 conducted “diabetic” training for staff on 10/06/2023. S1 stated that training was provided to staff that would care for C1. S1 stated that additional staff training would be provided to staff who were not working on 10/06/2023. Based on the gathered information, C1 moved in on 09/28/23, the facility did not facilitate training needed before staff working with C1. The training occurred (2) days before C1 moved out. Therefore, there is sufficient evidence to support the allegation mentioned above.



An exit interview was conducted and copy of the Complaint Report was provided to the Licensee Voneric Johnson (A1)
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6