198602406-10-11-2021-11-AS-EMAZ-CGS2NA-20220728173226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602406
Report Date: 08/19/2021
Date Signed: 10/11/2021 04:05:08 PM

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
06/15/2021 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20210615111742

FACILITY NAME:	ALABASTER ELDERLY CARE		FACILITY NUMBER:	198602406
ADMINISTRATOR:	DAVIS, DELORES		FACILITY TYPE:	740
ADDRESS:	9825 8TH AVENUE		TELEPHONE:	(323) 971-2964
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90305
CAPACITY:	6	CENSUS:	DATE:	08/19/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Andrea Whitehead		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident not able to return to facility.

INVESTIGATION FINDINGS:

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This report serves as an amendment to clarify finding. It does not supersedes the complaint investigation findings reflected on report created 8/19/2021.
On 8/19/2021 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted a subsequent complaint investigation at above facility. LPA arrived at facility and was greeted by staff Andrea Whitehead. LPA explained the purposed of the visit was complete investigation for the allegations listed above and was granted access to the facility.

The investigation consisted of the following:
On 6/22/2021 LPA Cifuentes conducted a tour of facility grounds. Facility grounds consist of a living room, kitchen, dining area, 3 resident bedrooms, 2 bathrooms, back yard with shaded area and detached garage which houses the facilities office. LPA interviewed staff 1 (S1) and staff 2 (S2) as well as Resident 1-resident 5(R1-R5). On 8/19/2021 LPA Cifuentes interviewed administrator, staff 3 (S3) and staff 4 (S4). LPA requested and received the following documents: staff and client rosters, medical files and admissions agreement for resident 1 (R1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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-20210615111742

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: ALABASTER ELDERLY CARE	FACILITY NUMBER: 198602406
	VISIT DATE: 08/19/2021

NARRATIVE

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The investigation revealed the following:

Allegation: Resident not able to return to the facility.

The complainant alleges that R1 was brought to the hospital for wound care and after being treated was turned away by the facility, as they would not be able to provide care to R1. LPA Cifuentes spoke with administrator Delores Davis, who stated she called Kaiser to arrange for a pick-up for R1, as she was concerned with both their behavior and a stage II pressure injury they had when they came into the facility. R1 was picked up on 6/14/2021. Administrator Davis states she received a call from the hospital on 6/14/2021 and was told nothing was wrong and they would be sending R1 back to facility. Administrator Davis requested further tests be conducted, as R1 seemed to be in pain and had no pain pills. Ambulance showed up at the facility around 11pm on 6/14/2021 and Administrator Davis instructed them to take R1 back to the hospital for further testing. LPA Cifuentes reviewed hospital medical record for R1. Once further testing was completed, R1 was returned to facility on 6/15/2021 with new prescription orders. Per social worker notes on page 25, Administrator Davis spoke with social worker on 6/15/2021 and expressed concern over R1’s pain levels and pressure injury, stating that she felt further testing was necessary was necessary, so she could properly manage R1’s care while in the facility. Further notes, also on page 25, state that on 6/15/2021 hospital doctor spoke with R1’s Neurologist, who agreed that a new medication should be given to R1 to address pain from pressure injury.

Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R-1)'s service records, incident report, and interviews conducted and found no evidence to support the allegations: "Resident not able to return to facility."".

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Delores Davis and a copy of the report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC9099 (FAS) - (06/04)

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