198602608-4-19-2022-28-AS-WSHO-CEARSA-20220510131624

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602608
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:46:03 PM

Unsubstantiated

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
11/04/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211104142735

FACILITY NAME:	GROVE AT CERRITOS, THE		FACILITY NUMBER:	198602608
ADMINISTRATOR:	BRITTNEY BUCHANNAN		FACILITY TYPE:	740
ADDRESS:	11000 NEW FALCON WAY		TELEPHONE:	(562) 865-9500
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	163	CENSUS: 128	DATE:	04/19/2022
		UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Business Manager, Carmen Galicia		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not seek medical attention for resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit. LPA met with Business Manager, Carmen Galicia and explained the reason for the visit. The initial complaint visit was conducted by LPA Nina Galarza on 11/10/21.

The investigation consisted of the following: During the initial visit, LPA Galarza interviewed Director of Assisted Living, La'Keisha Phillips. During today's visit, LPA Vasallo interviewed 6 staff which included caregiver, Medication Technician's (Med Tech) and front office staff. LPA also interviewed 4 residents. Resident #1's (R1) file was reviewed which included assessments, medication records, progress notes and incident reports.

The investigation revealed the following: It's alleged R1 had a change of condition on 10/24/21 and staff failed to call 911 in a timely manner. Facility documented the incident on a report. According to the report, a staff member notified R1's family that R1 appeared to be weak and needed assistance with toileting.
Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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-20211104142735

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: 04/19/2022

NARRATIVE

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When family arrived they asked staff to call 911. Paramedics checked R1's blood sugar and it was 345. R1 was transferred to the hospital. According to medication documentation, R1 had been refusing insulin medication since September 2021. Facility was updating the family and physician on each occurrence. On 10/18/21, facility documented again that R1 refused insulin medication. Physician noted "Will hold insulin for now". From 10/19/21 to 10/24/21, facility did not assist with insulin due to physician's orders.

On 10/22/21, facility noted R1 refused to eat lunch. Family was notified. On 10/24/21, facility noted R1 appeared weak in the morning. R1 was assisted with toileting and was escorted to the dining hall for breakfast. R1 ate very little. Facility checked on R1 at noon the same day and R1 appeared to be resting. R1 was asked if he/she wanted to go to the hospital and R1 said no. Family was notified of the incident. Family visited the facility at approximately 1:20 pm and asked staff to call 911 because R1 appeared weak.

R1 is no longer a resident of the facility and was therefore not interviewed. Residents interviewed describe the staff as "good" or "great". Staff interviewed remember R1 and indicated R1 regularly refused medication and started to refuse meals. Caregiver also indicated R1 sometimes refused assistance with toileting. On 10/24/21 staff did not call 911 because it was not unusual for R1 to refuse to eat or refuse care. Staff did not give insulin since the physician ordered the insulin be held. Based on the information obtained, the allegation is unsubstantiated.

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.

Exit interview held. A copy of the report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC9099 (FAS) - (06/04)

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