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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602223
Report Date: 03/02/2024
Date Signed: 03/02/2024 01:02:14 PM

Substantiated


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
10/02/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20231002090146
FACILITY NAME:HEARTWELL HOME 2FACILITY NUMBER:
198602223
ADMINISTRATOR:RODERICK, MARIA SIAFACILITY TYPE:
735
ADDRESS:203 E 219TH STTELEPHONE:
(310) 989-8017
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:4CENSUS: 4DATE:
03/02/2024
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Maria Roderick TIME COMPLETED:
10:47 AM
ALLEGATION(S):
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9
Staff failed to respond to the changes in residents’ health in a timely manner.
Resident's hygiene needs are not being met.
INVESTIGATION FINDINGS:
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On 03/02/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Administrator (A1: Maria Roderick). LPA conducted a risk assessment prior to entering the facility. A1 informed LPA that the facility has no COVID cases nor do any of the clients or direct support personnel have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following:
A 24-hour visit was conducted by Licensing Program Analyst (LPA) Ernand Dabuet for health & safety purposes and to ensure the wellbeing of clients in care. The investigation consisted of the following: a tour of the physical plant and all clients were in the facility. During today’s visit, LPA reviewed the following documents.
(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
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 8
Control Number 11-AS-20231002090146
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: HEARTWELL HOME 2
FACILITY NUMBER: 198602223
VISIT DATE: 03/02/2024
NARRATIVE
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Resident Roster (dated 04//08/21), Staff Roster & DSP Work Schedules (dated: 06/01/23), Client #1 Face Sheet (dated: 04/30/18), ID/Emergency Info (dated 03/10/22), Individual Personal Plans (Period: 02/21/23), Medication Administration Records (dated: September & October 2023), Physician’s Orders (dated: 09/01/23 &10/01/23) Admissions Agreements (dated: 05/31/18), Identification/Emergency Information (dated: 03/03/20), Behavioral Support Plans (dated: 03/31/23), Physicians Reports (dated: 07/31/23 & 01/24/23), Appraisal/Needs and Services Plan (dated: 01/10/23), Incident Report (dated: 09/27/23), Body Check Charts (dated: 09/14/23 and 09/27/23) Medical/Specialist Visits (dated: 01/15/23 thru 09/14/23), CDSS Photography Report (dated: 10/18/23), Torrance Memorial Hospital Medical Records (dated: 09/27/23 thru 10/05/23).

The complaint was referred to the California Department of Social Services Investigations Branch and was assigned to investigator (Johnny Canto) which included a review of medical records (dated: 10/18/23 thru 10/05/23); Photography Report (dated: 10/18/23), Law Enforcement Reports (dated: 01/01/22 – 12/07/23). Interviews of medical services personnel (Witness #1-#2); Facility Staff (#A1, #S1, #S2, #S3, #S4 #S5); and Clients (#1, #2).

INVESTIGATION REVEALED THE FOLLOWING:

Allegation #2: Staff failed to respond to the changes in residents’ health in a timely manner.


It is alleged there were concerns of neglect with client #1(C1) while in care at this facility.

Investigator Johnny Canto conducted interviews with facility staff, physicians, and investigative leads along with medical and facility records revealed that (C1) had numerous visits to the bathroom on 09/27/23 during the night. At 10:30 pm (C1) was seated to urinate for 15-20 minutes, at 11:10 pm (C1) was escorted back to the room and appeared weak and knelt on the bedroom floor, at 12:00 am (C1) appeared weak, leaning on the hallway walls (C1) seated to urinate for 15-20 minutes, (C1) was assisted at 1:00 am for another bathroom visit and remained weak and unbalanced, (C1) remained seated in the toilet for 15-20 minutes, at 3:00 am (C1) was found sitting on the floor bedroom floor (C1) urinated in a seated position for 10 minutes, at 4:00 am(C1) was on found again on the bedroom floor remained weak and unbalanced (C1) remained seated to urinate for 10 minutes.

(Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
10/02/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20231002090146

FACILITY NAME:HEARTWELL HOME 2FACILITY NUMBER:
198602223
ADMINISTRATOR:RODERICK, MARIA SIAFACILITY TYPE:
735
ADDRESS:203 E 219TH STTELEPHONE:
(310) 989-8017
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:4CENSUS: 4DATE:
03/02/2024
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Maria Roderick TIME COMPLETED:
10:47 AM
ALLEGATION(S):
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2
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9
Resident sustained multiple unexplained bruising.
INVESTIGATION FINDINGS:
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On 03/02/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Administrator (A1: Maria Roderick). LPA conducted a risk assessment prior to entering the facility. A1 informed LPA that the facility has no COVID cases nor do any of the clients or direct support personnel have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following:
A 24-hour visit was conducted by Licensing Program Analyst (LPA) Ernand Dabuet for health & safety purposes and to ensure the wellbeing of clients in care. The investigation consisted of the following: a tour of the physical plant and all clients were in the facility. During today’s visit, LPA reviewed the following documents.
(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20231002090146
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: HEARTWELL HOME 2
FACILITY NUMBER: 198602223
VISIT DATE: 03/02/2024
NARRATIVE
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Resident Roster (dated 04//08/21), Staff Roster & DSP Work Schedules (dated: 06/01/23), Client #1 Face Sheet (dated: 04/30/18), ID/Emergency Info (dated 03/10/22), Individual Personal Plans (Period: 02/21/23), Medication Administration Records (dated: September & October 2023), Physician’s Orders (dated: 09/01/23 &10/01/23) Admissions Agreements (dated: 05/31/18), Identification/Emergency Information (dated: 03/03/20), Behavioral Support Plans (dated: 03/31/23), Physicians Reports (dated: 07/31/23 & 01/24/23), Appraisal/Needs and Services Plan (dated: 01/10/23), Incident Report (dated: 09/27/23), Body Check Charts (dated: 09/14/23 and 09/27/23) Medical/Specialist Visits (dated: 01/15/23 thru 09/14/23), CDSS Photography Report (dated: 10/18/23), Torrance Memorial Hospital Medical Records (dated: 09/27/23 thru 10/05/23).

The complaint was referred to the California Department of Social Services Investigations Branch and was assigned to investigator (Johnny Canto) which included a review of medical records (dated: 10/18/23 thru 10/05/23); Photography Report (dated: 10/18/23), Law Enforcement Reports (dated: 01/01/22 – 12/07/23). Interviews of medical services personnel (Witness #1-#2); Facility Staff (#A1, #S1, #S2, #S3, #S4 #S5); and Clients (#1, #2).

INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Resident sustained multiple unexplained bruising.

It was reported that there were concerns of potential physical abuse with client #1 (C1) due to multiple bruises.



Investigator Johnny Canto conducted interviews with facility staff, physicians, and investigative leads along with medical and facility records revealed that (C1) had numerous visits to the bathroom on 09/27/23 during the night shift. Facility body assessment noted no injuries on 09/26/23. (C1) was admitted to Torrance Memorial Hospital on 09/27/23 for weakness, and possible UTI and noted several body discoloration/ulcers. The facility body assessment noted several discolorations on 09/27/23 by the direct care staff #2 (S2). According to medical records, (C1) may have experienced a cardioembolic infarct. On 12/06/23 at 4:00 pm, direct care staff #1 (S1) stated (C1) was found on the floor twice and attempted to pick up (C1) via (C1’s) underarms. (S1) indicated (C1) was not at baseline and had a change in condition during (S1’s) shift and that (C1) appeared weak and leaned on (C1’s) right side onto the walls while walking.
(Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20231002090146
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: HEARTWELL HOME 2
FACILITY NUMBER: 198602223
VISIT DATE: 03/02/2024
NARRATIVE
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On 12/22/23 at 10:46 am, medical physician witness #1 (W1) noted (C1) is on blood thinning medications. (W1) noted blood thinner medication make the skin and elasticity of the skin prominent for discolorations. On 10/18/23 between 11:34 am - 1:16 pm interviews conducted with (staff #2- #3). Interviews with staff #1 on (12/06/23) and staff #4-#5 on (12/21/23) all denied physical abuse.

Harbor Regional Center Department of Community Services and the Los Angeles Sheriff’s Department Carson Station conducted separate investigations and determined no evidence of dependent adult abuse.

Based on the evidence gathered, interviews conducted, and medical records reviewed, 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 of PHYSICAL ABUSE: “Resident sustained multiple unexplained bruising” is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the complaint report was provided to the Administrator Maria Sia Roderick.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20231002090146
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: HEARTWELL HOME 2
FACILITY NUMBER: 198602223
VISIT DATE: 03/02/2024
NARRATIVE
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Medical Records noted that (C1) had a diagnosis of a UTI and “it is possible that (C1) suffered a cardioembolic infarct (possibly left ACA territory) given the urinary incontinence and right-side deficits.

On 12/06/23 at 4:00 pm, (S1) had stated that (C1) was not at baseline and had a change in condition during (S1’s) shift. Interview with (S3-S4) stated that (S1) should have called and informed management when (S1) observed (C1’s) change in condition and management would have directed (S1) to seek medical attention for (C1).

Based on evidence gathered, interviews conducted, records reviewed, and photographs, the preponderance of evidence standard has been met; therefore, the allegation of NELECT/LACK OF CARE: “Staff failed to respond to the changes in residents’ health in a timely manner” is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D).

Allegation #3: Resident's hygiene needs are not being met.


It was reported that (C1) had unkept toenails. (C1’s) toenails were noted to be unkept overgrown and required trimming. On 02/09/24 between 09:49 am - 10:27 am, (LPA) Dabuet interviewed Administrator #1 (A1) who stated clients have podiatrist appointments. The last podiatrist appointment was missed in July 2023 for (C1). (A1) claimed that podiatrist appointments are usually scheduled every four to six weeks. It was an oversight from the staff that (C1) had missed the July 2023 appointment and no scheduled reminder was provided by the podiatrist.


Investigator Johnny Canto conducted interviews on 10/18/23 between 11:34 am - 1:16 pm interviews with (staff #2- #3). along with staff #1 on (12/06/23) and staff #4-#5 on (12/21/23) all claimed that daily body assessments are conducted with clients. Staff should have observed (C1’s) toenails were unkept and a mandatory follow-up appointment was required.

Based on evidence gathered, interviews conducted, records reviewed, and photographs, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE: “Resident's hygiene needs are not being met” is found to be found to be SUBSTANTIATED.

(Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20231002090146
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: HEARTWELL HOME 2
FACILITY NUMBER: 198602223
VISIT DATE: 03/02/2024
NARRATIVE
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and a citation issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights was provided to the Administrator Maria Sia Roderick.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20231002090146
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: HEARTWELL HOME 2
FACILITY NUMBER: 198602223
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2024
Section Cited
CCR
85075.4(a)(c)
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Observation of the Client (a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning. (c) The licensee shall bring observed changes,,, deterioration of health condition, to the attention of the client's physician and authorized representative...
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Licensee/Administrator shall ensure a training for all staff on Title 22, Section 85075.4 “Observation of the Client” is conducted and send the sign in sheets and training materials to the CCLD by the Plan of Correction (03/16/24) due date Attn: Ernand.Dabuet@dss.ca.gov
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This requirement is not met as evidenced by: Staff failed to regularly observe client #1for changes deterioration of health condition to the attention to client’s physician and authorized representatives in a timely manner. This violation poses a potential health and safety to persons in care.
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Type B
03/16/2024
Section Cited
CCR
85077(a)
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Personal Services (a) Licensees shall provide necessary personal assistance and care, as indicated in the needs and services plan, with activities of daily living including but not limited to dressing, eating, and bathing.
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Licensee/Administrator shall ensure a training for all staff on Title 22, Section 85077 “Personal Services” is conducted and send the sign in sheets and training materials to the CCLD by the Plan of Correction (03/16/24) due date Attn: Ernand.Dabuet@dss.ca.gov
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This requirement is not met as evidenced by: Staff failed to provide necessary personal assistance and care with client #1 hygiene needs for unkept overgrown toenails. This violation poses a potential health and safety to persons in care.
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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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8