198602608-10-27-2020-28-AS-MVAO-BWYSTB-20210105130913

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602608
Report Date: 10/26/2020
Date Signed: 10/27/2020 04:02:46 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/10/2019 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191010135736

FACILITY NAME:	GROVE AT CERRITOS, THE		FACILITY NUMBER:	198602608
ADMINISTRATOR:	CRENSHAW, CAMILLE		FACILITY TYPE:	740
ADDRESS:	11000 NEW FALCON WAY		TELEPHONE:	(562) 865-9500
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	163	CENSUS: 132	DATE:	10/26/2020
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Angelina Gallegos		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident was left on the floor for an extended period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos initiated a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Office Manager Angelina Gallegos.

The initial complaint investigation was conducted on 10/14/2019 by LPA Rea. During the initial investigation, interview was conducted with the administrator and staff #1 (s1). Specific doucments from Resident #1's (R1) file were obtained.

On todays visit. LPA Villalobos obtained a copy of the resident and staff roster, copy of the special incident report involving R1, as well as interviewed staff #2 (s2). LPA Villalobos was unable to interview R1 due to that person not living in the facility any longer and being unavailable to contact via phone call.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020

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 28-AS-20191010135736

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GROVE AT CERRITOS, THE	FACILITY NUMBER: 198602608
	VISIT DATE: 10/26/2020

NARRATIVE

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The investigation revealed the following: R1 had an unwitnessed accident in the bathroom on 9/25/19. As staff were responding to residents call for assistance, R1 also had a visitor who came out of the room asking for help. Staff arrived to R1 and decided that 911 emergency call needed to be made. Paramedics arrived and took R1 to the hospital where R1 was discharged and returned to the facility the same day. Review of R1's file show that there is no need for additional status checks from staff as R1 does not have a history of falling. Interviews show that R1 was provided assistance in a timely manner and not left on the floor for an extended period of time. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did or did not happen therefore the above allegation is found to be UNSUBSTANTIATED.

A telephonic exit interview was conducted with Angelina and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

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