198602567-3-12-2024-11-AS-EMAZ-D3SVGG-20240328162532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602567
Report Date: 03/11/2024
Date Signed: 03/12/2024 07:56:31 AM

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
08/15/2023 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20230815161749

FACILITY NAME:	REGENCY PALMS LONG BEACH		FACILITY NUMBER:	198602567
ADMINISTRATOR:	CARLA MARIANO		FACILITY TYPE:	740
ADDRESS:	117 E 8TH STREET		TELEPHONE:	(562) 432-9260
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY:	91	CENSUS: 58	DATE:	03/11/2024
		UNANNOUNCED	TIME BEGAN:	11:19 AM
MET WITH:	Kenia Padilla-Sanchez		TIME COMPLETED:	04:01 PM

ALLEGATION(S):

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Facility failed to follow resident's advance health care directive
Faciliy staff is falsifying records

INVESTIGATION FINDINGS:

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On 03/11/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to the facility listed above to deliver finding for the allegation listed above. LPA met with Executive Director, Kenia Padilla-Sanchez, and explained the purpose of today’s visit.

On a previous visit conducted on 08/24/23, LPA toured the facility, interviewed Staff (S1-S4), interviewed Residents (R2-R6) received, and reviewed Resident R1’s medical records, incident reports, nurse notes, staff notes, doctor visit reports, doctor’s orders, hospital discharge papers, DNR, Advanced Health Care Directive, and all legal documents.

The investigation revealed the following:

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 11-AS-20230815161749

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: REGENCY PALMS LONG BEACH	FACILITY NUMBER: 198602567
	VISIT DATE: 03/11/2024

NARRATIVE

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Allegation: Facility failed to follow resident’s Advanced Health Care Directive.
It is alleged the facility was not providing information to an Agent, on the Advanced Health Care Directive, regarding a resident’s care in 2019.
During the file review of R1’s resident file, LPA reviewed the Identification and Emergency Information (LIC601) licensing form. LPA found only (1) contact listed on this form. The initial form was filled out on 11/08/18 and signed by R1 upon admission. During file review, LPA observed R1’s Advance Health Care Directive listed (2) emergency contacts (co-agents). Upon additional review if the Advance Health Care Directive, states that the two listed “shall make decisions for me in accordance with what my agent determines to be in my best interest” (pg.2). During reviews of Resident R1’s Service Notes, LPA observed that R1's daughter was informed of incidents in 2019. LPA also observed a note which indicates that former Director of Wellness Meriza De La Cruz got clarification from R1's fiduciary about R1's Advance Health Care Directive 0n 05/02/19. Fiduciary clarified to facility staff that both R1's son and daughter are on her Advance Health Care Directive and that if there is a major medical condition R1's son will respond right away as he lives a few minutes away from the facility and R1's daughter lives in Northern California. LPA observed in the notes that the daughter was added to the Identification and Emergency Information form as well as the fiduciary per the daughter’s request. Additionally, LPA observed that R1’s son and daughter were notified regarding care and treatment of R1.

During interviews with Staff (S1-S4) four (4) out of four (4) stated if there are co-agents listed on the Advanced Health Care Directive, they notify both agents

Continued LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230815161749

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: REGENCY PALMS LONG BEACH	FACILITY NUMBER: 198602567
	VISIT DATE: 03/11/2024

NARRATIVE

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regarding health-related matters in an emergency. Additionally, LPA found R1 had a fiduciary conservator who was notified when R1 required medical treatment. LPA conducted interviews with staff (S1-S3), and three (3) out of three (3) staff members stated they contacted the fiduciary regarding transportation, appointments, treatments, and medications that required a co-pay. S1 stated the facility is does not provide medical treatment of any kind, nor makes medical decisions for a resident, that is between the medical team and the family. S1 stated they will contact the hospital to check on the status of the resident but does not receive information on their care nor treatment while they are there, and the only information they receive is the discharge orders and updated medications. The facility does assist in making the follow-up appointments which they would contact the closest contact listed that could assist in transporting the resident or the fiduciary regarding arranging for transportation for the resident. LPA observed in the service notes all calls to the fiduciary, and R1’s son was regarding transportation, scheduling appointments, medication refills, and pick-ups, not about care or treatment.
Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Facility staff falsifying records

It is alleged the facility is falsifying communication records.
During interviews with staff (S1-S4), LPA asked if staff has falsified any resident records,four (4) out of four (4) stated staff have not falsified any documents and are unaware of

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230815161749

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: REGENCY PALMS LONG BEACH	FACILITY NUMBER: 198602567
	VISIT DATE: 03/11/2024

NARRATIVE

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any other staff falsifying resident documents. During interviews with Residents (R2-R6) they were asked if they had any knowledge of staff falsifying resident records, five (5) out of five (5) Residents stated they have no knowledge of that occurring. LPA conducted a review of communication notes in R1’s Service Record and was unable to find records appearing to be falsified.
Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were observed or cited during today’s visit.

LPA conducted an exit interview with Executive Director, Kenia Padilla, and a copy of this report was emailed due to technical issues with LPA's printer.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC9099 (FAS) - (06/04)

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