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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601965
Report Date: 08/28/2024
Date Signed: 09/06/2024 10:17:39 AM

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
06/28/2024 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20240628165018
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: 1DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator Von'Eric Johnson TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident sustained injury while in care.
Facility staff failed to properly supervise resident.
INVESTIGATION FINDINGS:
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On 08/28/24 Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent visit to deliver complaint findings, LPA met with Administrator Von'Eric Johnson as the purpose of the visit was explained.

The investigation consisted of the following: On 07/03/24 LPA obtained a staff and client roster, pertinent documents associated with this complaint for client #1 (C1), and pertinent documents associated with this complaint for Staff #1-3 (S1-S3). On 07/03/24 between 11am- 11:15 am LPA conducted Interview with Administrator (A1). On 07/08/24 LPA conducted telephone interview with staff # 3 (S3), on 08/09/24 at 12:50 pm LPA obtained the remaining pertinent documents associated with this complaint. On 08/13/24 LPA conducted telephone interview with staff #4 (S4).

The investigation revealed the following:
Allegation: Resident sustained injury while in care.
It is being alleged that client was hospitalized due to skin breakdown after client was taken outdoors without shoes.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
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 3
Control Number 11-AS-20240628165018
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: 08/28/2024
NARRATIVE
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On 07/03/24 LPA interviewed A1 regarding the allegation above, A1 confirmed the allegation above. A1 stated that blisters and redness were observed on the bottom of C1’s feet during LVN’s body assessment. On 07/03/24 LPA was unable to interview Client #1 (C1) as C1 remains admitted at Long Beach Memorial and due to communication barriers, LPA was unable to interview C2 as C2 was not at the facility, LPA was unable to conduct interview with client #3 (C3) as (C3) did not want to be interviewed. On 07/03/24 LPA reviewed incident reported dated 06/23/24, incident report indicated C1 was admitted into Long Beach Memorial for blisters and G-Tube leakage. On 07/03/24 LPA conducted interview with W2 regarding the allegation above, per W2 facility administrator was very candid and straight forward when reporting the incident. On 07/08/24 LPA conducted telephone interview with staff # 3 (S3) regarding the allegation above, S3 denied the allegation above and reported that C1 was taken outside for 1 minute and did not show any signs of pain. S3 continued to report that C1 did not like wearing shoes and would take shoes off right away. On 07/08/24 LPA attempted to conducted interview with staff #1 (S1) however there was no contact made. On 08/13/24 LPA interviewed Staff #4 (S4) regarding the allegation above, S4 confirmed the allegation and reported blisters were observed on C1’s feet during body assessment.

Allegation: Facility staff failed to properly supervise resident.

It is being alleged that staff #2 (S2) left (2) clients unsupervised inside a running van. On 07/03/24 LPA interviewed A1 regarding the allegation above, A1 confirmed the allegation above. A1 stated that a client reported the incident to A1, A1 then proceeded to ask S2 about the allegation, S2 confirmed and reported S2 was unaware this was prohibited. On 07/03/24 LPA was unable to interview Client #1 (C1) as C1 remains admitted at Long Beach Memorial and due to communication barriers, LPA was unable to interview C2 as C2 was not at the facility, LPA was unable to conduct interview with client #3 (C3) as (C3) did not want to be interviewed. On 07/03/24 LPA reviewed incident report received by department on 06/24/24. On 07/08/24 LPA attempted to conducted interview with staff #2 (S2) however there was no contact made. On 07/08/24 LPA conducted telephone interview with staff # 3 (S3) regarding the allegation above, S3 reported having no knowledge on the allegation above. On 08/13/24 LPA interviewed Staff #4 (S4) regarding the allegation above, S4 reported having no details about the allegation above.

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 1 and 6 are being cited on the attached LIC 9099D.

exit interview conducted, appeal rights explained and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240628165018
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: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
80065(a)
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Personnel requirements
Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
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Licensee and Administrator is to Retrain all staff on personal rights and personnel requirements to ensure the safety of all clients in care is being met. Proof of retraining shall be sent to LPA by POC due date.
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Based on interviews and records review the licensee failed to meet this requirement as C1 was not provided with safe, healthful and comfortable accommodations which resulted in C1 to be admitted into the hospital which poses a health and safety concern.
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Type A
08/29/2024
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision
The licensee shall provide care and supervision as necessary to meet the client's needs.
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Licensee and Administrator is to Retrain all staff on transportation protocols to ensure the safety of all clients in care is being met. Proof of retraining shall be sent to LPA by POC due date.
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Based on interviews and records review the licensee failed to meet this requirement as client(s) were left unaccompanied in a running vehicle which poses a health and safety concern.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3