198602549-3-24-2022-11-AS-EMAZ-CDAVFP-20220408162416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602549
Report Date: 03/24/2022
Date Signed: 03/24/2022 06:22:11 PM

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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2020 and conducted by Evaluator Don Senaha

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200603084736

FACILITY NAME:	SUNRISE AT PALOS VERDES		FACILITY NUMBER:	198602549
ADMINISTRATOR:	GOLLIA, ALBERTO		FACILITY TYPE:	740
ADDRESS:	25535 HAWTHORNE BLVD		TELEPHONE:	(310) 377-7425
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	115	CENSUS: 64	DATE:	03/24/2022
		UNANNOUNCED	TIME BEGAN:	10:21 AM
MET WITH:	Administrator - Kelly Jacobs		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff failed to seek resident timely medical attention after falling.
Resident sustained unexplained injury.

INVESTIGATION FINDINGS:

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On 03/24/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Executive Director Kelly Jacobs.

The investigation consisted of the following: LPA requested resident roster, staff roster and other service documents on 03/24/2022. LPA conducted interviews with residents (R1-R7), Executive Director and staff (S1-S5). A plant inspection of the facility was conducted 03/24/2022.

Investigation revealed:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

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-20200603084736

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
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE AT PALOS VERDES	FACILITY NUMBER: 198602549
	VISIT DATE: 03/24/2022

NARRATIVE

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Allegation: Staff failed to seek resident timely medical attention after falling.

It is alleged that staff failed to seek resident timely medical attention after falling. LPA conducted interviews with Administrator, residents (R1-R7) and staff (S1-S5).

Residents (R1-R7) stated they get staff to tend to them in a timely manner when they call for any reason. Administrator stated staff reports all falls that require medical attention or care to the wellness nurse immediately. On 4/25/2020, resident (R1) was experiencing pain inside her left thigh and a hematoma was observed. Resident (R1) primary care physician called by facility and primary care physician recommended a transfer to the hospital for more evaluation. Facility called 911 immediately on 4/25/2020 and resident (R1) was transported to the hospital. POA for Resident (R1) was notified. Resident (R1) was released on the same day from the hospital and follow up appointment with primary care physician scheduled for 05/04/2020. Witness (W1) who is the POA of resident (R1) stated the facility reports everything in a timely manner to me and “the place is fantastic for us”. LPA observed and obtained training for reporting requirements for staff. LPA observed and obtained an incident report reported to Community Care Licensing Division in a timely manner on 04/30/2020.

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated

Allegation: Resident sustained unexplained injury.

It is alleged that a resident sustained an unexplained injury. LPA conducted interviews with Administrator, residents (R1-R7) and staff (S1-S5).

Residents (R1-R7) stated they would tell staff if they obtained an injury. Residents (R1-R7) stated staff has never physically hurt or harmed them. Residents (R1-R7) stated staff has never physically hurt or harmed any other resident in the facility. Administrator reported the injury on an incident report on 04/30/2020 in a timely manner. Administrator stated staff gets along with all residents. Administrator stated she has never seen or staff has never reported any type of physical abuse in the facility. Administrator stated that all unexplained injuries noticed on residents are reported immediately to the wellness nurse by staff. Administrator reported

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200603084736

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
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE AT PALOS VERDES	FACILITY NUMBER: 198602549
	VISIT DATE: 03/24/2022

NARRATIVE

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resident (R1) is very independent with a walker. Staff (S1-S5) stated they get along with all the residents. Staff (S1-S5) stated they have never seen or reported any type of physical abuse of a resident by another staff member. Staff (S3, S5) stated resident (R1) is very independent. Staff (S3) stated resident (R1) does everything on her own and “will speak up if anything is wrong”. Staff (S3) stated resident (R1) woke up one day and the hematoma was there. Witness (W1) who is the POA of resident (R1) stated the facility reports everything in a timely manner to me and “the place is fantastic for us”. Witness (W1) stated the injury was “because of her medical condition”. LPA obtained and reviewed progress notes. Progress notes stated on 04/25/2020 at 08:24am resident (R1) was in severe pain. Progress notes stated on 4/25/2020 at 09:44am 911 was called per POA request. Progress notes stated on 04/27/2020 per primary care physician, “resident may have had a spontaneous bleed”. LPA observed and obtained training for reporting requirements for staff.

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated

There were no deficiencies found at the time of the visit.

An exit interview was conducted with Executive Director Kelly Jacobs, and a hard copy was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC9099 (FAS) - (06/04)

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