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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602567
Report Date: 01/18/2024
Date Signed: 01/18/2024 12:56:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230206134252
FACILITY NAME:REGENCY PALMS LONG BEACHFACILITY NUMBER:
198602567
ADMINISTRATOR:CARLA MARIANOFACILITY TYPE:
740
ADDRESS:117 E 8TH STREETTELEPHONE:
(562) 432-9260
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY:91CENSUS: 52DATE:
01/18/2024
UNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:ADMINISTRATOR KENIA PADILLATIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility personnel are not sufficient in numbers at all times to prevent residents from falling.
Facility personnel are not sufficient in numbers at all times to answer resident call buttons in a timely manner.
Facility personnel are not sufficient in numbers at all times to meet resident needs for incontinence care.
Facility personnel are not sufficient in numbers at all times to meet resident needs for showering.
INVESTIGATION FINDINGS:
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THIS REPORT SUPERSEDES THE REPORT DATED 02/13/2023 FOR CLARIFY THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS HAVE CHANGED: SUBSTANTIATED
On 02/13/2023 around 09:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation for Regency Palms Long Beach facility to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Kenia Padilla (A1).
Investigation consisted of: LPA Calderon interviewed Administrator Kenia Padilla A1, S1-S8 and R1-R6. These interviews were conducted on 02/13/2023 and 07/27/2023. On 02/13/2023 and 07/27/2023 LPA Calderon obtained and reviewed in service training: Call log notes (dated March, April, May 2023), incontinence care training (dated 05/27/2023), Toileting log training (dated 1/18/23, 5/27/23), Staff Rounds endorsement training (dated 5/11/23, 5/23/23), Caregiver duties training (dated 5/17/23). Body checks and shower training (dated 5/4/23), Transfer/2-person assistance training (dated 2/18/23), Checking bathrooms and resident rooms at end of shift training (dated 2/9/23), Medical records training (dated 2/7/23) for residents in care.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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 5
Control Number 11-AS-20230206134252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 01/18/2024
NARRATIVE
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Regarding Allegation #1: Facility personnel are always not sufficient in numbers to prevent residents from falling.
This complaint alleged that facility personnel are not sufficient to prevent residents from falling. LPA Calderon conducted an interview with A1. A1 expressed that the facility is not understaffed, and residents do not fall due to lack of staffing. A1 said that the facility has floaters that work on each floor as needed. A1 expressed that staff need to do is call for assistance and a nurse, LVN or floater will be there to help with residents’ needs. LPA Calderon conducted an interview with S1-S8. 8 out of 8 staff expressed that the facility is understaffed, and residents fall due to health condition and staffing issues. 8 out of 8 staff state that the resident to staff ratio on average is 8 to 1 per floor. 8 out of 8 staff said that there are higher ratios on different floors and that there are 2 staff floaters that help with the care of residents. 8 out of 8 staff state that there are 2 staff med-tects in the facility to support the care staff with the needs of residents but for the most part there is only 1 staff member on any floor and falls do happen. LPA Calderon attempted to interview R1-R6. 6 out of 6 residents were unable to communicate due to impairments.

Regarding Allegation #2: Facility personnel are always not sufficient in numbers to answer resident call button in a timely manner.

This complaint alleged that there is not enough staff to answer residents call button. LPA Calderon conducted an interview with A1. A1 expressed that the day shift and night shift are different because most residents are sleeping on the night shift and there are less residents that push the call button. A1 expressed that there is an 8 to 1 ratio and 2 floaters and 2 med-tecks that work each day and night shift and any time a call button is pushed staff answers. A1 expressed that there are no staffing issues and there are enough staff to answer call buttons within 3 to 7 minutes. LPA Calderon conducted an interview with S1-S8. 8 out of 8 staff said that most of the time the call button is not pushed at night as residents are sleeping. 8 out of 8 staff expressed that on average the call button is pushed more often in the daytime as most residents are out of bed. 8 out of 8 staff state that there are not enough staff to answer the resident call button and on average it takes 5 to 10 minutes depending on the resident situation. LPA Calderon attempted to interview R1-R6. 6 out of 6 residents were unable to communicate due to impairments.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20230206134252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 01/18/2024
NARRATIVE
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Regarding Allegation 3: Facility personnel are always not sufficient in numbers to meet resident needs for incontinence care.
This complaint alleged that there are not enough staff to meet incontinence care. LPA Calderon conducted an interview with A1. A1 expressed that not all residents in care need incontinence services. A1 expressed that most residents diaper can be changed by one staff member. A1 expressed that there are 2 staff floaters and 2 staff med-tects that work every shift. A1 expressed that if staff needs help with residents’ incontinence care staff can make a call for assistance. A1 expressed that there is no staffing issue at the facility and there are enough staff to take care of the residents with incontinence care. LPA Calderon conducted an interview with S1-S8. 8 out of 8 staff said that there are staffing issues in the facility. 8 out of 8 staff said that not all residents in the care need incontinence services. 8 out of 8 staff expressed that due to staffing issues it takes longer to care for residents with incontinence needs. LPA Calderon attempted to interview R1-R6. 6 out of 6 residents were unable to communicate due to impairments. On 07/07/2023 LPA Calderon reviewed staff training records for incontinence care (dated 5/27/2023) and log notes for March and April and May 2023 which support staff providing incontinence care to resident.

Regarding Allegation #4: Facility personnel are always not sufficient in numbers to meet resident needs for showering.
This complaint alleged that there are not enough staff to meet resident showering needs. LPA Calderon conducted an interview with A1. A1 expressed that staffing needs are different from the day shift to night shift and are different care needs per floor. A1 expressed that there are 2 staff floaters and 2 staff med-tects that work each shift. A1 expressed that not all residents are given a shower at the same time or on the same day and that there is always another staff member to support the floor caregiver when needed. A1 expressed that no resident goes without a shower. LPA Calderon conducted an interview with S1-S8. 8 out of 8 staff said that the staff to resident ratio changes per floor. 8 out of 8 staff expressed that giving a shower or bath to a resident is a 2-person job and most times there is only 1 staff member to give a resident a shower. 8 out of 8 staff said there are staffing issues and not enough staff to clean all residents timely. LPA Calderon attempted to interview R1-R6. 6 out of 6 residents were unable to communicate due to impairments. On 07/27/2023 LPA Calderon reviewed staff training records for showering residents (dated 05/04/2023). LPA Calderon reviewed log notes for March and April 2022 for staff giving showers to residents. Reviewed caregivers’ duty (dated 5/17/2023), and staff rounds training (dated 05/11/2023). LPA Calderon noted staff trained on how to shower resident, but limited staff have the training.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230206134252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 01/18/2024
NARRATIVE
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Although the allegation may have happened or is valid, there is a preponderance of evidence to prove the alleged violation(s) did occur, therefore the allegation “facility personal are not sufficient in numbers at all times to prevent residents from falling” “ facility personnel are not sufficient in numbers at all times to answer resident call button in a timely manner” “facility personnel are not sufficient in numbers at all times to meet resident needs for incontinence care” “facility personnel are not sufficient in numbers at all times to meet resident needs for showering” is substantiated. California Code of Regulations, Title 22, Division 6 are cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Kenia Padilla (A1).
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230206134252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....This requirement is not met as evidenced by:
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Administrator will hire enough staff to meet resident to staff ratio and ensure enough staff to meet residents needs.
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Based on interviews, and record review, the licensee failed to ensure adequate staffing to meet resident’s needs which posed a potential health risk to residents 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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5