198602039-4-15-2024-11-AS-UCOL-D5VMWC-20240603095806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602039
Report Date: 04/15/2024
Date Signed: 04/15/2024 04:34:27 PM

Unsubstantiated

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
04/11/2024 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240411130558

FACILITY NAME:	REGENT VILLA RETIREMENT HOME		FACILITY NUMBER:	198602039
ADMINISTRATOR:	GORDON, JENNI		FACILITY TYPE:	740
ADDRESS:	201 W WARDLOW RD		TELEPHONE:	(562) 595-6529
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	188	CENSUS: 140	DATE:	04/15/2024
		UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Jenni Gordon, Administrator		TIME COMPLETED:	04:53 PM

ALLEGATION(S):

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Staff altered resident's record

INVESTIGATION FINDINGS:

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On 04/15/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Jenni Gordon, Administrator (S1), and the purpose of the visit was explained. S1 and LPA toured the facility.

The investigation consisted of the following:
On 04/15/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed four (4) out of one-hundred and forty (140) residents (R1-R4) and four (4) out of forty (40) staff (S1-S4). LPA interviewed two (2) out of four (4) witnesses (W1-W4). Witness two and witness four (W2, W4) were not available for interview.

Report continues, see LIC9099C

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

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 11-AS-20240411130558

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: REGENT VILLA RETIREMENT HOME	FACILITY NUMBER: 198602039
	VISIT DATE: 04/15/2024

NARRATIVE

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The investigation revealed the following:

Regarding the allegation: "Staff altered resident's record.". It has been alleged that staff has altered resident one's Physican Orders for Life-Sustaining Treatment (POLST).

Interviews revealed that all 4 staff and all 4 residents have denied the allegation, while one (1) (W3) out of 2 witnesses informed LPA that R1 had a fall at Los Angeles Downtown Medical Center (LADMC) and one out of 2 witnesses (W1) informed that R1 had made a choice to file his POLST for Do Not Resuscitate and additionally to deny artificial means of nutrition, including feeding tubes, using his own mental capacity.
Record reviews revealed that R1 had began to deny one of his medications during May 2023, slowly increasing his refusal of one medication through July 2023. R1 later began to completely refuse this medication in December 2023. Then, January 12, 2024, R1 refused all medications.

Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was conducted with Jenni Gordon, Administrator (S1), and a copy of this report has been provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC9099 (FAS) - (06/04)

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