198602190-6-9-2022-11-AS-UCOL-CGQSKQ-20220727135706

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602190
Report Date: 06/03/2022
Date Signed: 06/09/2022 09:47:05 AM

Unsubstantiated

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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2022 and conducted by Evaluator Jey Cardenas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220526104318

FACILITY NAME:	CASA DEL SOL RESIDENCE		FACILITY NUMBER:	198602190
ADMINISTRATOR:	JACOBS, DOV E		FACILITY TYPE:	740
ADDRESS:	11606 11602 W WASHINGTON BLVD		TELEPHONE:	(323) 678-4426
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90066
CAPACITY:	12	CENSUS: 6	DATE:	06/03/2022
		UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Valorie Hansen, Head Nurse		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff yelled at resident.
Facility assigned resident a physician without resident's consent.
Resident is being retaliated against.
Resident feels threatened by staff.
Illegal eviction.

INVESTIGATION FINDINGS:

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Due to system error; this report is a recreation of complaint report visit date: 06/03/22. Signature is on original report hardcopy that's on file. Licensing Program Analyst (LPA) Jey Cardenas conducted an initial 10- day complaint visit to the above facility to investigate allegations listed above. Upon arrival at the facility LPA meet with staff (S1) LPA explained the reason for today’s visit and conducted a Covid-19 risk assessment.
The investigation consisted of the following: LPA Cardenas reviewed Resident#1 (R1) file and obtained copies of Physician report, admission agreement, progress notes, doctors progress notes, and care plan. LPA Interviewed Staff#1-Staff#3 (S1-S3) and Residents#1-5 (R1-R5) Resident#6 (R6) was not at the facility at time of visit. LPA toured plant.
It is being alleged that: S1 recently yelled at resident for not seeing a doctor and threatened with an eviction. The Facility assigned a doctor without resident’s consent and resident feels retaliated against for filing a complaint. On 6/3/2022 LPA Cardenas reviewed physician report: diagnosis includes depression, paranoia, and Diabetes. On 6/3/22 LPA Cardenas interviewed W1 who indicates being pleased with

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

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-20220526104318

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
MONTERY PARK, CA 91754

FACILITY NAME: CASA DEL SOL RESIDENCE	FACILITY NUMBER: 198602190
	VISIT DATE: 06/03/2022

NARRATIVE

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the care and supervision the facility is providing, no concerns regarding abuse. W1 has not seen an eviction notice for R1. Regarding allegation Staff yelled at resident. On 6/3/2022 LPA Cardenas interviewed S1-S3 who indicate that residents haven’t complained about staff yelling at them, nor has staff witnessed other staff yelling at residents. On 6/03/22 LPA Cardenas interviewed residents; R2-R4 indicate staff don’t yell at them. R5 likes the facility, no other comments nor complaints.

Regarding allegation Facility assigned resident a physician without resident's consent. On 6/3/22 LPA Reviewed R1 care plan- “discussed facility contract regarding need to have a doctor to check in as often as needed.” Per psych notes resident was seen, chart reviewed, care plan discussed with staff. Resident presents paranoid, guarded delusional, restless, and intervalley pre-occupied. Residents is paranoid that food is being poisoned. Resident has poor insight to illness. Per Personnel progress notes dated 11/4/21; There has been a change of MD services per resident refusal to see Dr. Peck. Per family instructions another MD has been assigned. On 6/03/22 LPA Cardenas interviewed S1-S3 who indicate residents have the option to choose their own physician, however, there is also a facility doctor available if needed. Facility Dr. Peck provided medical services to R1 since admission through 03/20/21, R1 refused to continue seeing him and accused Dr. Peck of looking at resident the wrong way. S2 indicates that R6 is not at the facility because resident is at physician of choice. Facility doesn’t force physicians on residents. On 6/3/22 LPA Cardenas interviewed residents R2 and R3 indicate they have the option to choose their own doctor. R4 didn’t answer question.

Regarding allegation Resident is being retaliated against. On 6/3/2022 LPA Cardenas interviewed S1-S3 who indicate that residents haven’t complained about feeling retaliated against by staff. On 6/03/22 LPA Cardenas interviewed residents; R2-R4 who indicate they haven’t felt retaliated against.

Regarding allegation Resident feels threatened by staff. On 6/3/2022 LPA Cardenas interviewed S1-S3 who indicate that residents haven’t complained about staff threatening them, nor has staff witnessed other staff threatening residents. On 6/03/22 LPA Cardenas interviewed residents; R2-R4 indicate staff have not threatened them.

Regarding allegation Illegal eviction. On 6/3/2022 LPA Cardenas interviewed S1 who indicates that none of the residents have been issued an eviction notice at this time. Facility would like to avoid an eviction and is working with R1s family to ensure resident receives appropriate medical care due to R1s continued refusal.Based on LPA’s interviews and record reviews, LPA did not find sufficient evidence to support the allegations, Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report to be provided to facility representative.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

LIC9099 (FAS) - (06/04)

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