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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602405
Report Date: 10/11/2023
Date Signed: 10/11/2023 03:57:25 PM

Document Has Been Signed on 10/11/2023 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ANEW DIRECTION ADULT LIVINGFACILITY NUMBER:
198602405
ADMINISTRATOR:PATRICIA DUFRENNEFACILITY TYPE:
735
ADDRESS:2300 S PACIFIC AVETELEPHONE:
(909) 210-0365
CITY:SAN PEDROSTATE: CAZIP CODE:
90731
CAPACITY: 72CENSUS: 63DATE:
10/11/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Patricia Dufrenne AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On 10/11/23, at 1:30pm an Office Meeting was held at the El Segundo Office. Present during the meeting was Regional Manager Benita Yates, Licensing Program Manager Janae Hammond, Licensing Program Analyst (LPA) Jeremiah Randle, and Licensee/Administrator Patria Dufrennne. The purpose for today’s meeting is to deliver findings pertaining to a questionable death and neglect/lack of supervision.

An initial Case Management Visit was conducted by LPA Alfonso Iniguez on 07/05/23 who was met by the Assistant Administrator (Joyce Garcia). During that visit, LPA Iniguez gathered information surrounding the death of Client #1. LPA reviewed and obtained copies of the following documents: client tracking notes, staff rounds for the months of May, June, and July of 2023 Staff Work Schedule- LIC 500. Copy C1-C5 client records. LPA conducted interviews with the following Staff #1 – Staff #3 (S1-S3) and Client #2 – Client #11 (C2-C11). LPA reviewed 07/02/23 and 07/03/23 PM video recording. In addition, LPA requested a copy of the L.A. County Coroner’s Report, LAPD Report, Death Certificate, and a copy of the CCTV video footage from 07/02/23 at 5:00PM – 07/03/23 at 2:00AM. LPA toured the facility’s physical plant for the health and safety of residents in care. The c investigation was conducted by the Department of Social Services, Investigator Heidy Bendana that included interviews and reviewing copies of LAPD report, L.A.F.D. report, EMS report, L.A. County Coroner’s Report, Death Certificate, and facility staff and client rosters.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ANEW DIRECTION ADULT LIVING
FACILITY NUMBER: 198602405
VISIT DATE: 10/11/2023
NARRATIVE
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The investigation provided sufficient evidence to substantiate questionable. LPA reviewed Los Angeles Police Department (LAPD) report, Los Angles Fire Department (LAFD) report, Emergency Medical Services (EMS) report, L.A. County Coroner’s Report, and Death Certificate indicated that drug overdose was the cause of unnatural death for Client #1. Administrator disclosed that Staff #2 (Jesus Bonifacio) failed to conduct rounds check at 2200 hours; consequently, Staff #2 "thinks" they conducted rounds check approximately 2300 hours. Client #1’s reporting and death report (provided by the facility) showed Staff #2 conducted rounds check at 2330 hours. Had Staff #2 conducted rounds check at 2200 hours, Staff #2 could have been alerted that clients gathered in the bedroom - which facility policy indicates visiting in the resident rooms is not permitted - would have alerted staff that residents were gathering in the room with the purpose of drug use; especially since the night before (07/02/23) Client #1’s death, there was an incident of drug overdose that involved Client #3 and other clients (Client #2, Client #6). Staff negligence in failing to conduct rounds check every two (2) hours allowed clients to gather in the bedroom and use illegal drugs. Additionally, the facility failed to progressively heighten rounds check and failed to attribute the drug overdose the night prior as a warning sign of drug use in the facility that led to Client #1’s unnatural death. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of QUESTIONABLE DEATH: Staff neglected Client #1 resulting in the client's unnatural death is found to be SUBSTANTIATED.
The investigation provided sufficient evidence to substantiate neglect/lack of supervision against Administrator (Patricia Dufrenne, BSN/RN). hours.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/11/2023 03:57 PM - It Cannot Be Edited


Created By: Jeremiah Randle On 10/11/2023 at 01:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANEW DIRECTION ADULT LIVING
FACILITY NUMBER: 198602405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2023
Section Cited
CCR
80064(a)(2-3)

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Administrator - Qualifications and Duties.
The administrator shall have the following qualifications:
Knowledge of the requirements for providing the type of care and supervision needed by clients… Knowledge of and ability to comply with applicable law and regulation.

This requirement was not met as evidence by:
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Licensee/Administrator shall read Title 22, Section “Administrator - Qualifications and Duties” and send a written statement to the CCLD/El Segundo ASC Regional Office by the Plan of Correction (POC) date.
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Based on records reviewed and interviewed conducted the Administrator failed to ensure proper protocols were followed to address the drug usage in the facility. This poses an health & safety risk to residents in care
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Type A
10/12/2023
Section Cited
CCR85065(b)

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The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This requirement is not met as evidence by:

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Licensee/Administrator shall read Title 22, Section "Personnel Requirements" and send a written statement to the CCLD/El Segundo ASC Regional Office by the Plan of Correction (POC) date. Licensee to ensure a training is scheduled with staff to go over facility procedures and provisions of supervision. Civil penalty assessed.
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Based on records review and interviews conducted the Licensee failed to ensure facility staff employed by the facility were able to meet the clients needs resulting in the clients gathering to use illegal drugs. This poses an immediate health & safety risk to clients 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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/11/2023 03:57 PM - It Cannot Be Edited


Created By: Jeremiah Randle On 10/11/2023 at 01:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANEW DIRECTION ADULT LIVING
FACILITY NUMBER: 198602405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2023
Section Cited
CCR
80072(a)(2)

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Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidence by:
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Based on observation, interviews conducted and records reviewed the Licensee failed to ensure staff were conducting rounds effective to ensure clients did not gather in bedrooms. This resulted in clients using illegal drugs and Client #1 death This poses an immediate health & safety risk to residents in care.
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Licensee/Administrator shall read Title 22, Section "Personal Rights" and send a written statement to the CCLD/El Segundo ASC Regional Office by the Plan of Correction (POC) date. Civil penalty assessed.

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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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ANEW DIRECTION ADULT LIVING
FACILITY NUMBER: 198602405
VISIT DATE: 10/11/2023
NARRATIVE
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Based on interviews, LAPD report, LAFD report, EMS report, L.A. County Coroner’s Report, Death Certificate, facility documents indicated that Staff #2 (Jesus Bonifacio) failed to conduct rounds check at 2200 hours; consequently, Staff #2 "thinks" they conducted rounds check approximately 2300.Staff #2 conducted rounds check at 2330 hours. Had Staff #2 conducted rounds check at 2200 hours, Staff #2 could have been alerted that clients gathered in the bedroom - which facility policy indicates visiting in the client rooms is not permitted - would have alerted staff that clients were gathering in the room with the purpose of drug use; especially since the night before (07/02/23) there was an incident of drug overdose that involved Client #3 and other clients (Client #2, Client #6). Staff negligence in failing to conduct rounds check every two (2) hours allowed clients to gather in the bedroom and use illegal drugs. Additionally, the facility failed to progressively heighten rounds check and failed to attribute the drug overdose the night prior as a warning sign of drug use in the facility.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of Neglect/Lack of Supervision: Staff failed to supervise clients resulting in clients to overdose on illegal drugs is found to be SUBSTANTIATED.


According to the California Code of Regulations (Title 22, Division 6, Chapter 1 & 6), the following deficiencies have been observed and citations issued (ref. LIC 809D). Civil penalty assessed. At this time an Enhance Civil Penalty is being considered by the department for Questionable Death.

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to Administrator Patria Dufrenne
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC809 (FAS) - (06/04)
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