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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602099
Report Date: 01/11/2022
Date Signed: 01/11/2022 03:57:13 PM



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
01/06/2022 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20220106152122
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: 70DATE:
01/11/2022
UNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Eleanor BarrientosTIME COMPLETED:
04:23 PM
ALLEGATION(S):
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Facility is withholding resident's receipt of their retirement benefits.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegation listed above. LPA met with Eleonor Barrientos the facility administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 01/11/2022 LPA Coronel LPA interviewed the administrator and assistant administrator Michalene Johnson. LPA requested copies of and reviewed facility records and resident R1's resident records.

The investigation revealed the following: It is alleged that the facility has not updated the Social Security Administration that R1 is no longer a resident at this facility which prevents R1 from obtaining retirement benefits. On 12/18/2021 resident R1 left this facility to move in with family in another state. On 12/21/2021 R1 contacted the assistant administrator via telephone and requested that the facility informs Social Security of R1's new home address and to forward R1's benefit balance to their new home address.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
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 2
Control Number 11-AS-20220106152122
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: 01/11/2022
NARRATIVE
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On 01/04/2022 the assistant administrator contacted the Social Security Department and updated them of R1's new address and requested that benefit balance were to be forwarded to R1. On 01/07/2021 the assistant administrator obtained R1's benefit balance and is in the process of mailing it to R1.

Regarding the allegation "Facility is withholding resident's receipt of their retirement benefits." 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.

An exit interview was conducted. A copy of this report was provided to Eleonor Barrientos the facility administrator.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2