198602099-3-13-2021-11-AS-MVAO-BZ7T3A-20210317142202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602099
Report Date: 03/12/2021
Date Signed: 03/13/2021 11:12:22 AM

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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2020 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20201228161125

FACILITY NAME:	CORAL OAKS CARE LIVING		FACILITY NUMBER:	198602099
ADMINISTRATOR:	ELEANOR BARRIENTOS		FACILITY TYPE:	740
ADDRESS:	4271 CARLIN AVE		TELEPHONE:	(310) 763-4881
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	84	CENSUS: 63	DATE:	03/12/2021
		UNANNOUNCED	TIME BEGAN:	03:03 PM
MET WITH:	Eleonor Barrientos		TIME COMPLETED:	04:04 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to report missing resident to appropriate agencies.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Eleonor Barrientos the facility administrator.

The investigation consisted of the following: On 01/06/2021 LPA conducted a virtual tour of the facility’s physical plant, interviewed the administrator and requested R1’s resident records. On 03/05/2021 LPA conducted record reviews of regional office records, facility records and R1’s resident records. On 03/08/2021 LPA interviewed the Administrator, Staffs S1 and S2 and reviewed R1’s resident records. On 03/08/2021 LPA interviewed witness F1.

Report continued, please see LIC9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

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-20201228161125

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CORAL OAKS CARE LIVING	FACILITY NUMBER: 198602099
	VISIT DATE: 03/12/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following: On 03/08/2021 S1 stated that: “On 04/20/2020 R1 was transferred from the facility to Downey PIH via 911 call.”

On 03/08/2021 S2 stated that: "Around Thanksgiving of last year (11/26/2020) R1’s family F1 called the facility and spoke to me to find out how R1 was doing. I called the Downey PIH hospital to get an update, they wanted me to send a request via fax and I was not able to give R1’s current location but I told F1 that I was going call them when I find out. A week later I received a call from Downey PIH stating that R1 was discharged to Country Villa South skilled nursing facility on 05/11/2020. I tried calling F1 the following 2 days but there were no answers."

On 01/06/2021 the administrator stated that: “On 01/04/2021 the Long-Term Care Ombudsman called to find R1’s location. On 01/05/2021 I found out that on 06/14/2020 R1 was transported from Country Villa South to Los Angeles Downtown Medical Center and on 12/01/2020 R1 was discharged from Los Angeles Downtown Medical Center to Torrance Care Center a skilled nursing facility.

On 03/05/2021 LPA conducted record reviews and did not observe records of R1’s discharge from Downey PIH hospital to Country Villa South on 05/11/2020 and R1's transfer from Country Villa South to Los Angeles Downtown Medical Center on 06/14/2020.

Regarding the allegation “Staff failed to report missing resident to appropriate agencies.” Based on LPAs observations, interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC9099-D.

A telephonic exit interview was conducted. Plans of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided via email for signature.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20201228161125

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CORAL OAKS CARE LIVING	FACILITY NUMBER: 198602099
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/19/2021 Section Cited CCR 87506(b)(13)	1 2 3 4 5 6 7	87506(b)(13) Resident Records. Each resident’s record shall contain at least the following information: Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The admiistrator agreed to develop a plan outlining the steps to be taken by the facility to ensure that continuing records of residents illness' and medical care are available to staff for update and review. Proof of correction will be submuitted by POC due Date.
	8 9 10 11 12 13 14	Based on record reviews and interviews conducted the licensee failed to ensure that continuing records of R1's medical care were included in R1's resident records which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 03/19/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish to the licensing agency...: A written report shall be submitted to the licensing agency within seven days of the occurrence of any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The admiistrator agreed to develop a plan outlining the steps taken by the facility to ensure that written report are submitted to the licensing agency within seven days of the occurrence of any incident which threatens the welfare, safety or health of any resident. Proof of correction will be submuitted by POC due Date.
	8 9 10 11 12 13 14	Based on LPA observation, record reviews and interviews conducted, the licensee failed to ensure that written reports are submitted to the licensing agency and to the person responsible for the resident within seven days of the R1's unexplained absence, which poses a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3