198602542-11-15-2023-11-AS-MVAO-CXYW4P-20231127155752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602542
Report Date: 11/15/2023
Date Signed: 11/15/2023 02:39:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
06/09/2023 and conducted by Evaluator Lizeth Villegas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230609154611

FACILITY NAME:	CHELSEA RESIDENTIAL CARE		FACILITY NUMBER:	198602542
ADMINISTRATOR:	HARRISON, HONORA		FACILITY TYPE:	735
ADDRESS:	2030 W 144 STREET		TELEPHONE:	(310) 515-4757
CITY:	GARDENA	STATE: CA	ZIP CODE:	90249
CAPACITY:	4	CENSUS: 3	DATE:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	11:59 AM
MET WITH:	Administrator Zoie Clarke		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care.

INVESTIGATION FINDINGS:

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On 11/15/23 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Administrator Zoie Clarke as the purpose of today’s visit was explained.

The investigation consisted of the following: On 06/13/23 Licensing Program Analyst (LPA) Ana Soto initiated a complaint investigation for the allegation listed above. LPA requested copies of the following documents: Client roster, Staff roster, Face sheet, IPP, Physician's Report, Functional Capability assessment, Psycho/social assessment, Admission agreement, Quarterly report, Medication Administration Record (MAR) from (May and June,) Medical report (ER/Hospital visit,) Facility daily notes, Behavior tracking report, and Incident Reports (ER visit).
On 06/13/23 the case was referred to California Department of Social Services (CDSS) Investigations Branch. On 06/21/23 the case was assigned to IB Investigator Douglas Real.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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-20230609154611

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CHELSEA RESIDENTIAL CARE	FACILITY NUMBER: 198602542
	VISIT DATE: 11/15/2023

NARRATIVE

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On 06/30/23 investigator Douglas Real interviewed hospital Witness (W1) via telephone, on 07/26/23 interviews were conducted with Resident #1-3 (R1-R3), Staff #1-2 (S1-S2), and on 09/07/23 interview was conducted with a Witness #2 (W2).

On 11/13/23, LPA Lizeth Villegas interviewed the facility Administrator (A1) via telephone.

The investigation revealed the following: Allegation: Resident sustained unexplained bruising while in care.

It is being alleged resident had bruises on the arms that look like somebody held or pushed on the residents arms, and the bruising on residents legs look different than on arms. On 06/30/23 investigator Douglas Real interviewed (W1) regarding the above allegation, per W1 R1 was admitted to hospital with numerous bruises on upper thighs in varying degrees of healing. W1 stated that R1 has a behavior of hitting self. On 07/26/23 investigator Douglas Real interviewed R1-R3, 3 of the 3 residents interviewed denied the allegation above. R1-R3 did not report any abuse or neglect by any of the facility employees. On 07/26/23 Investigator Douglas Real interviewed S1-S2, 2 of the 2 staff interviewed denied the above allegation. Per S1-S2. 1 of 2 staff interviewed stated that R1 has a behavior of hitting self when frustrated. On 09/07/23 Investigator Real interviewed W2, per W2,W2 has no information to support the allegation. W2 reported that visits are conducted at the facility and there are no concerns of safety for R1-R3.

On 11/13/2023 LPA interviewed Administrator (A1) regarding the above allegation, per A1 all 3 clients have behaviors and R1 has self-injurious behaviors. A1 denied any residents being abused in care.

On 11/14/23, LPA Villegas conducted a review of R1 Individual Program Plan (IPP) from Westside Regional Center which states R1 has outburst, attempted wandering and property destruction.

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 allegation is deemed unsubstantiated.

Exit interview conducted with Administrator Zoie Clarke and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

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