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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602608
Report Date: 06/07/2022
Date Signed: 06/07/2022 10:49:23 AM

Substantiated


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
01/14/2021 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210114084218
FACILITY NAME:GROVE AT CERRITOS, THEFACILITY NUMBER:
198602608
ADMINISTRATOR:CRENSHAW, CAMILLEFACILITY TYPE:
740
ADDRESS:11000 NEW FALCON WAYTELEPHONE:
(562) 865-9500
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:163CENSUS: 133DATE:
06/07/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kianny Soto, Director of Assisted LivingTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Resident is not being rotated resulting in pressure injuries.
Resident's diapering needs are not being met.
Facility staff are not following resident's dietary needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit to deliver the findings for the above three allegations. LPA met with the Director of Assisted Living, Kianny Soto, and Executive Director, Sahar Mosalla, to explain the purpose of the visit.

Investigation consisted of the following:
On the initial visit dated 1/15/21, LPA conducted a video call to review the food supplies, physical plant, and the medication room. LPA requested copies of the staff roster to include the contact numbers, food menu, and documents for Residents #1 - #5: Physician’s Report, Appraisal/Needs & Services Plan, Hospice and/or facility notes, MAR log for October 2020 through January 2021.

On 9/30/21, LPA Chan conducted an on-site visit to interview 4 Staff and 10 Residents. LPA requested for the staff roster, resident roster, and facility notes pertaining to Resident #1. The allegation – Resident is not being rotated resulting in pressure injuries was investigated by an Investigation Branch personnel.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
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 7
Control Number 28-AS-20210114084218
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: 06/07/2022
NARRATIVE
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Investigation revealed the following:

Regarding allegation - Resident is not being rotated resulting in pressure injuries. The Department of Social Services Investigation Branch (IB) Investigator, Peter Zertuche, conducted interviews and obtained medical (Hospice) records for Resident #1 to determine the findings of this allegation. The information obtained from the interviews revealed that Resident #1 was not being rotated resulting in pressure injuries. Per the Mt. Olive’s Hospice agency care plan, Resident #1 was admitted to this hospice agency with a stage 2 wound in the coccyx area on 12/21/2020. The notes stated to rotate every 2 hours and to change diapers often to ensure the coccyx area is dry at all times. The interviews revealed that caregivers did not change the diaper nor reposition regularly during some shifts. Per interview with Resident #1’s family member, the individual stated no staff came in to check on resident while visiting for 4 hours on one of the visits. Although Staff interviewed denied not rotating resident every 2 hours, the resident’s wound eventually worsened to a stage 3 by 2/1/21. There was no new plan of care or contact with the doctor once the wound worsened. Based on interviews and record review, there are supporting evidence to substantiate this allegation.

Regarding allegation - Resident’s diapering needs are not being met. LPA reviewed Resident #1 facility’s Service Plan and hospice visit notes which indicated that Resident #1’s diaper needs to be changed often to keep buttock area dry, preventing the open wound to occur or get worse. LPA Chan interviewed 3 care staff who stated they changed Resident #1 every 2 hours. Interviews conducted by Investigation Branch (IB) Zertuche also revealed that Resident #1 was found with soiled diapers during some visits by the hospice nurse and/or shift change of staff. According to the Mt. Olive’s Hospice Agency notes, the hospice nurses documented Resident #1’s diaper being soiled for at least 5 of their visits. It was also noted that Resident’s dressing in the buttock area was soiled with urine and/or feces while being changed by the hospice nurse. Based on documents and interviews gathered, there is sufficient evidence to show that the resident’s diapering needs were not met.

(Continue on LIC9099C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20210114084218
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: 06/07/2022
NARRATIVE
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Regarding allegation – Facility staff are not following resident’s dietary needs. It was alleged that Resident #1 was given orange juice when not supposed to and was also given ice cream and milk. According to the Mt. Olive Hospice Visit Notes, it is specified to avoid giving Resident #1 orange juice which could cause the blood sugar level to increase. Staff were instructed to give Glucerna (food supplement) if resident refuses to eat and was indicated on the hospice care plan. LPA Chan interviewed 2 Staff who provided care to Resident #1. One staff stated that Resident #1 was near the end of life, therefore, felt it was okay to give a little bit of orange juice, while the other did not know if the doctor instructed not to give orange juice. It was also noted on some of the hospice nurse visits, the caregivers were reminded not to give orange juice to the resident which caregivers verbalized understanding. However, orange juice was observed by resident’s bedside during some of the hospice visits. As for dairy products, staff knew Resident #1 was allergic to dairy and did not provide any of it. Based on interviews and documentation, the facility staff did not follow the dietary plan and gave Resident #1 orange juice. There is sufficient evidence to support this allegation.

Based on interviews and documents, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM*** The issuance of an additional Civil Penalty is being considered based on health & Safety Code 1569.49(f); If the Department determines serious bodily injury occurred.




An exit interview was conducted. The Plan of Corrections were reviewed and developed with staff. A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20210114084218
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2022
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility....(b) (2) The licensee shall provide assistance in meeting necessary medical and dental needs...
This requirement is not met as evidenced by:
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The administrator shall conduct an in-service training with care staff to ensure they are repositioning residents at least every 2 hours. The POC shall be submitted to LPA by 6/21/22.
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Based on record reviews and interviews, the administrator did not ensure that Resident #1 was rotated frequently to prevent the wound from worsening which poses a potential health and safety risk to residents in care.
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Type B
06/21/2022
Section Cited
CCR
87625(b)(2)
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87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.
This requirement is not met as evidenced by:
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The administrator shall conducted an in-service with care staff to ensure they are changing residents' diapers as often as needed. The POC shall be submitted to LPA by 6/21/22.
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Based on interviews and record review, the administrator did not ensure that Resident #1's diaper is changed often to keep buttock area dry which poses a potential health and safety 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20210114084218
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2022
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements
(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
This requirement is not met as evidenced by:
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The Administrator will continue on-going training for staff to ensure residents' needs are met and what residents cannot have. The POC shall be submitted to LPA by 6/21/22.
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Based on interviews, the administrator did not ensure that Resident #1 is not provided with orange juice as stated on the hospice notes which poses a potential health and safety 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
01/14/2021 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210114084218

FACILITY NAME:GROVE AT CERRITOS, THEFACILITY NUMBER:
198602608
ADMINISTRATOR:CRENSHAW, CAMILLEFACILITY TYPE:
740
ADDRESS:11000 NEW FALCON WAYTELEPHONE:
(562) 865-9500
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:163CENSUS: 133DATE:
06/07/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kianny Soto, Director of Assisted LivingTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's medication is not being administered.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit to deliver the findings for the above allegation. LPA met with the Director of Assisted Living, Kianny Soto, and Executive Director, Sahar Mosalla, to explain the purpose of the visit.

Investigation consisted of the following:

On the initial visit dated 1/15/21, LPA conducted a video call to review the food supplies, physical plant, and the medication room. LPA requested copies of the staff roster to include the contact numbers, food menu, and documents for Residents #1 - #5: Physician’s Report, Appraisal/Needs & Services Plan, Hospice and/or facility notes, MAR log for October 2020 through January 2021.
On 9/30/21, LPA Chan conducted an on-site visit to interview 4 Staff and 10 Residents. LPA requested for the staff roster, resident roster, and facility notes pertaining to Resident #1 (R-1) .
(Continue on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20210114084218
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: 06/07/2022
NARRATIVE
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Investigation revealed the following:

In regards to allegation, resident’s medication is not being administered. It was alleged that Resident #1 (R-1) did not receive insulin because the facility stated “we are too busy.” According to interviews conducted by LPA Chan, R-1 self- administered the insulin. R-1 was able to self-administered until the health condition worsened and R-1 could no longer administer. Since the facility staff cannot administer the insulin on resident, they contacted the hospice agency who came to administer the injection. Based on facility’s medication record and hospice notes, there were documentation of resident’s inability to self-administer the insulin. The facility took the proper step to notify the hospice agency when resident refused or could not take the insulin.

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 occur, therefore the allegation is UNSUBSTANTIATED.



An exit interview was conducted with Ms. Soto. A copy of this report along with the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7