198602099-6-25-2024-11-AS-JHAD-D7FVDY-20240723162130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602099
Report Date: 06/21/2024
Date Signed: 06/25/2024 01:08:21 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
10/12/2023 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20231012094440

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: 67	DATE:	06/21/2024
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Administrator Eleanor Barrientos		TIME COMPLETED:	11:00 PM

ALLEGATION(S):

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Staff hit resident, resulting in resident sustaining a bruise

INVESTIGATION FINDINGS:

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On 06/21/24 Licensing program analyst (LPA) Villegas conducted a subsequential complaint visit to render findings regarding the allegation above. LPA met with Administrator (A1)Eleanor Barrientos, as the purpose of the visit was explained.

Th e investigation consist of the following: On 06/12/24 at 9:30 am Licensing program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation above. LPA Villegas met with Administrator (A1) Eleanor Barrientos as the purpose of the visit was explained. On 06/12/24 LPA Villegas obtained copies of the following: staff and resident rosters, and the following documents for R1: Emergency I.D. form (dated 08/02/23), admission agreement (dated 08/03/23), physicians report (dated: 08/07/23), physician’s orders, medication list, MAR, needs and service plan (08/08/23), and a copy of the incident report (dated 10/11/23). On 06/12/24 between 10am-11:30 am LPA conducted interviews with resident #2-6 (R2-R6) and between 11:30am-12:30 pm, LPA interviewed Administrator (A1), staff #1-3 (S1-S3). LPA Villegas unable to interview Resident #1 (R1) at the facility as R1 was out of the facility during the time of visit, however, later that day

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

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-20231012094440

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: CORAL OAKS CARE LIVING	FACILITY NUMBER: 198602099
	VISIT DATE: 06/21/2024

NARRATIVE

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(06/12/24) LPA Villegas was able to interview R1 via telephone.

The investigation revealed the following:

Allegation: Staff hit resident, resulting in resident sustaining a bruise.

It is being alleged that facility staff who assisted R1 with being changed pushed R1's hand against R1’s chest which resulted in a bruise. On 06/12/24 LPA interviewed A1 regarding the allegation above, A1 denied the allegation above and reported conducting an investigation when the incident was reported. A1 continued to report that while investigating, R1’s previous roommate who was present during the alleged incident denied the allegation in question, A1 also stated that R1 later reported that the incident was a misunderstanding. On 06/12/24 between 11:30 am-12:30 pm, LPA interviewed staff #1-3 (S1-S3) regarding the allegation above, 3 of 3 staff denied the allegation above and reported treating all residents with respect. On 06/12/24 between 10am-11:30 am LPA interviewed residents #2-6 (R2-R6) regarding the allegation above, 5 of 5 residents interviewed denied the allegation above and reported that staff treat them with respect and feel 5 of 5 residents interviewed reported feeling safe living at the facility. On 06/12/24 LPA Villegas was later able to interview R1 via telephone, R1 reported not having any recollection of the incident as it happened a long time ago however, R1 does recall having a bruise on chest. On 06/18/24 LPA reviewed R1’s physicians reported dated 08/07/23 which indicates in section named "history of skin condition or breaking" that R1 bruises easily. Based on interviews and records reviewed there is not enough evidence to support the allegation.

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

Exit interview conducted with Administrator Eleanor Barrientos, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC9099 (FAS) - (06/04)

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