198602608-8-11-2021-28-AS-MVAO-CBFSKZ-20220208125731

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602608
Report Date: 08/11/2021
Date Signed: 08/11/2021 01:55:02 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
07/08/2021 and conducted by Evaluator Nina Galarza

COMPLAINT CONTROL NUMBER: 28-AS-20210708152612

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: 116	DATE:	08/11/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Brittney Buchannan		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility did not share CCLD information to residents
Staff does not ensure safety of residents

INVESTIGATION FINDINGS:

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On 8/11/2021 Licensing Program Analysts (LPAs) Nina Galarza and Glenn Trueman conducted a subsequent complaint visit for the allegations listed above, initially reported on 7/8/2021. LPAs met with Administrator Brittney Buchannan and discussed the purpose of the visit.

The investigation consisted of interviews with Administrator S(1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4),Clients 1-6 (C1-C6)

In regards to the allegation: Facility does not share CCLD information to residents,

Administrator was interviewed on 7/14/2021, administrator stated all Provider Information Notices (PINs) are available to all residents in the front lobby area. LPAs did not obseve PINS in front lobby area on 7/14/2021 and on 8/11/2021. 6 out of 6 residents have stated that they do not know what PINS are and the facility does not provide PINS to residents.
Based on LPAs observations of no PINs in the front lobby area, interviews with staff and residents, the preponderance of evidence standard has been met , therefore the allegation above is found to be SUBSTANTIATED
Deficiencies were cited under California Code of Regulations, are being cited on attached 9099D

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

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 28-AS-20210708152612

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: 08/11/2021

NARRATIVE

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In regards to the allegation: Staff does not ensure safety of residents

On 7/14/2021 LPAs interviewed 6 residents. Each resident is given an emergency pendant to use. 5 out of 6 residents pendants were tested. 4 out of 6 resident pendants were not responded to at time of pendant test. 2 out of 6 residents stated that pendants are not responded to for more than 20 minutes. LPAs requested pendant response time documents from administrator. Administrator provided documents to LPA, which indicate pendant response time. Device Activity Report was reviewed, and it was revealed that on 7/14/2021, there were 31 instances with a response time of, or more than 20 minutes.
On 8/11/2021 LPAs interviewed administrator, administrator confirmed the time documented on the Device Activity Report is the time it took the staff to respond. Administrator stated all staff are trained to respond right away and to deactivate the device at time of response.
Based on LPAs observations of 4 out of 6 residents pendants were not responded to, interviews with residents and document review, the preponderance of evidence standard has been met , therefore the allegation above is found to be SUBSTANTIATED

Deficiencies were cited under California Code of Regulations, are being cited on attached 9099D

Exit interview was conducted, a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
07/08/2021 and conducted by Evaluator Nina Galarza

COMPLAINT CONTROL NUMBER: 28-AS-20210708152612

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: 116	DATE:	08/11/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Brittney Buchannan		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility in disrepair

INVESTIGATION FINDINGS:

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On 8/11/2021 Licensing Program Analysts (LPAs) Nina Galarza and Glenn Trueman conducted a subsequent complaint visit for the allegation listed above, initially reported on 7/8/2021. LPAs met with Administrator Brittney Buchannan and discussed the purpose of the visit.

The investigation consisted of interviews with Administrator S(1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4),Clients 1-6 (C1-C6)

0 out of 6 residents reported that they have not heard a fire alarm or smoke alarm. On 7/14/2021, LPA's toured resident rooms and observed smoke alarms functioning properly in rooms 126,129,106,201,239 and 262. On 7/14/2021 LPAs interviewed Building Manager, Carlos Monnarez, Building manager stated: there are two different alarms, smoke alarm and fire alarm. Smoke alarm is present in resident rooms to warn residents of smoke. Fire alarms are present outside the resident rooms, in hallways and other common areas, they are connected to a sprinkler system in resident rooms. Smoke alarm is activated when smoke is present. Fire alarm is activated when there is a fire at or more than 155 degrees Fahrenheit. The fire alarm and sprinklers will not be activated in any resident room unless there is a fire at or more than 155 degrees Fahrenheit.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report and Appeal Rights were provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20210708152612

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: 08/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/12/2021 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	Definitions (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide proof of training of staff to respond to residents and emergency devices, a signed log of staff who attended the training to LPA via email by P.O.C. date
	8 9 10 11 12 13 14	Based on interviews, 4 out of 6 resident pendants were not responded to at time of pendant test. 2 out of 6 residents stated that pendants are not responded to for more than 20 minutes. Based on Record review, Device Activity Report was reviewed, and it was revealed that on 7/14/2021, there were 31 instances with a response time of, or more than 20 minutes. Which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
Type B 08/13/2021 Section Cited CCR 87468.1(a)(10)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: 10) To be informed of the licensee’s policy concerning visits and other communications with residents, according to Health and Safety Code section 1569.313. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will certify all PINs will be posted and send picture proof to LPA via email by POC date
	8 9 10 11 12 13 14	LPAs did not obseve PINS in front lobby area on 7/14/2021 and on 8/11/2021. 6 out of 6 residents have stated that they do not know what PINS are and the the facility does not provide PINS to residents. Which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4