198602227-5-1-2023-11-AS-MVAO-CRVS7Q-20230516133755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602227
Report Date: 05/01/2023
Date Signed: 05/01/2023 09:22:06 AM

Unsubstantiated

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
09/19/2022 and conducted by Evaluator Jeremiah Randle

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220919210318

FACILITY NAME:	ASAHI RESIDENTIAL CARE		FACILITY NUMBER:	198602227
ADMINISTRATOR:	LACANILAO, EDNA		FACILITY TYPE:	740
ADDRESS:	18527 DORMAN AVE		TELEPHONE:	(310) 327-1633
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS:	DATE:	05/01/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kristine Lacanilao Administrator		TIME COMPLETED:	09:46 AM

ALLEGATION(S):

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Questionable death.
Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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On 02/03/23, Licensing Program Analyst (LPA) Jeremiah Randle conducted a subsequent unannounced visit at this facility and was greeted by Administrator Edna Lacanilao. LPA explained the purpose of this visit is to deliver the findings on the allegations mentioned above.

The investigation consisted of the following:
Licensing Program Analyst (LPA) Jeremiah Randle conducted a visit on 9/21/22 and 2/3/2023. LPA interviewed Administrator Edna Lacanilao (S1) and support staff (S2-S4). Resident R1 was not available to be interviewed due to death. LPA interviewed Residents (R2-R4) reviewed copies of staff/resident rosters, SIR reports, physician's reports, appraisals/needs and services plans, and service records of Residents.
The Department of Social Services investigator Peter Zertuchi conducted a separate investigation that included interviews with Complainant, Clinical Manager of Hospice Agency providing care, Hospice Nurse providing care to R1 and County Registrar to obtain cause of death information.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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-20220919210318

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: ASAHI RESIDENTIAL CARE	FACILITY NUMBER: 198602227
	VISIT DATE: 05/01/2023

NARRATIVE

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The investigation consisted of the following:

Allegation #1: Questionable death

It was alleged R1 was badly beaten while in care at the facility and passed away shortly after possibly due to R1 injuries. IB Investigator Peter Zerrtuche obtained and reviewed R1 Death Certificate on 10/20/22 and the review revealed; R1's cause of death was listed as prostate cancer with no other factors related to R1 death. The date and time of death was 05/01/2022 @2155 hours. The death certificate shows no autopsy was performed and the death was not reported to the coroner. IB investigator interviewed witnesses and conducted records review and there was no evidence to support R1’s death was caused by R1 being badly beaten.

LPA Randle conducted interviews of staff members (S1)-(S4) and support staff (S2-S4).. LPA reviewed documents from the facility. It was alleged that R1 sustained a Questionable death. Reporting party called CCL to report. On February 3, 2023 LPA interviewed Administrator Edna Lacanilao (S1) and support staff (S2-S4). LPA asked S1 if she was aware of the allegation listed above. S1 denied the allegation LPA also met with (S2-S4) all staff denied the allegation as to R1 or any other resident that had been in care. Resident R1 was not available to be interviewed due to death.

Based on CDSS Investigations Branch Interviewees and Investigation including LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20220919210318

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: ASAHI RESIDENTIAL CARE	FACILITY NUMBER: 198602227
	VISIT DATE: 05/01/2023

NARRATIVE

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Allegation #2: Resident sustained injuries while in care.

LPA interviewed Administrator Edna Lacanilao (S1) and support staff (S2-S4) regarding allegation Resident sustained injuries while in care. LPA asked S1 if she was aware of the allegation listed above. S1 denied the allegation regarding Resident R1 or any other resident sustaining injuries while in care. LPA interviewed staff (S2-S4) regarding allegation Resident R1 sustained injuries while in care. all staff denied the allegation as to R1 or any other resident in care.

LPA interviewed Residents (R2-R4) regarding sustaining injuries while in care. Residents (R2-R4) reported that they have not sustained injuries while in care at this facility. LPA conducted a visual observation of residents no signs of injury or trauma was noted.

Based on Investigation including LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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