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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602099
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:40:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
08/01/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20230801164010
FACILITY NAME:CORAL OAKS CARE LIVINGFACILITY NUMBER:
198602099
ADMINISTRATOR:ELEANOR BARRIENTOSFACILITY TYPE:
740
ADDRESS:4271 CARLIN AVETELEPHONE:
(310) 763-4881
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:84CENSUS: 75DATE:
08/08/2023
UNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Michalene JohnsonTIME COMPLETED:
04:47 PM
ALLEGATION(S):
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Facility has a bed bug infestation.
INVESTIGATION FINDINGS:
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 On 08/08/2023 Licensing Program Analyst (LPA) Richard conducted the 10 day complaint investigation visit regarding the allegations above. LPA spoke to assistant administrator Michalene Johnson regarding the above allegation.

The investigation consisted of the following: LPA Richard toured the facility grounds with assistant Administrator Johnson. LPA toured the residents' bedrooms R33, R34, R35, R36, and spoke to the residents regarding the allegations. LPA requested resident R1 records. Residents roster, Staff roster. Service agreement, invoices and bed bug treatment from the last four months.

In regards to the allegation Facility has bed bug infestation, based on records reviewed, observation, interviews conducted and information gathered there has been a bed bugs infestation for over a month now in resident R1. LPA Richard, Assistant Administrator Jonhson, caregive Rodriquez and resident R1, observed bed bugs in resident R35 at the time of visit.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
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 5
Control Number 11-AS-20230801164010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CORAL OAKS CARE LIVING
FACILITY NUMBER: 198602099
VISIT DATE: 08/08/2023
NARRATIVE
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Allegation:
Bed Bugs Resident Room

On 08/08/2023 LPA Richard Reviewed records received: On 07/13/2023, Pest control had sprayed resident room R35 and resident had to leave the room for 4 hours. LPA also conducted records reviews of staff, facility and resident records
Based on LPA observations, interviews and records reviewed which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter are being cited on the LIC 9099D.

An exit interview was conducted and a copy of the report and appeal rights was provided to the assistant administrator Michalene Johnson.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
08/01/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20230801164010

FACILITY NAME:CORAL OAKS CARE LIVINGFACILITY NUMBER:
198602099
ADMINISTRATOR:ELEANOR BARRIENTOSFACILITY TYPE:
740
ADDRESS:4271 CARLIN AVETELEPHONE:
(310) 763-4881
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:84CENSUS: 75DATE:
08/08/2023
UNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Michalene JohnsonTIME COMPLETED:
04:47 PM
ALLEGATION(S):
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Facility is not allowing Resident to place orders.
INVESTIGATION FINDINGS:
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On 08/08/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint visit at this facility, LPA was met with assistant Michalene Johnson. LPA explained the purposed of today's complaint investigation.

The investigation consisted of the following: during today's visit LPA Richard with assistant Johnson conducted the toured of the facility, interviewed eight (8) out of seventy five (75) Residents and interviewed five (5) out fifteen (15) staff. LPA also conducted records reviews of staff, facility and resident records.

The investigation revealed the following: It is being alleged that the facility is not allowing resident to place orders. During the tour of the facility. LPA observed resident R1 present at the facility, R1 stated that he could order anything he wants online. LPA interviews revealed the following: eight (8) out of seventy five (75) Residents were interviewed all stated they could order online. LPA interviewed five (5) out fifteen (15) staff none of them witnessed or told by residents that they couldn't order anything online.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230801164010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CORAL OAKS CARE LIVING
FACILITY NUMBER: 198602099
VISIT DATE: 08/08/2023
NARRATIVE
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Based on the information collected, record reviews and interviews, the Department found no evidence to support the allegation mentioned in this complaint.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the allegation is unsubstantiated.

No deficiency was cited during this visit.

An exit interview was conducted with assistant Administrator Michalene Johnson and a copy of this report was provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 11-AS-20230801164010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CORAL OAKS CARE LIVING
FACILITY NUMBER: 198602099
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. There has been reports of bed bugs on R35.
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Administrator to maintain contact with a licensed extreminator for bed bugs every month to inspect R1 room until the entire room is cleared of bed bugs.
Administrator will submit proof of correction to LPA via email Antonine.Richard@dss.ca.gov
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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.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5