198602620-11-30-2021-11-AS-MVAO-CCZPHL-20220330112008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602620
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:21:11 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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20210420152149

FACILITY NAME:	LONG BEACH RESIDENTIAL		FACILITY NUMBER:	198602620
ADMINISTRATOR:	BONZON, TED		FACILITY TYPE:	735
ADDRESS:	4201 EAST 10TH STREET		TELEPHONE:	(562) 433-2455
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90804
CAPACITY:	49	CENSUS: 45	DATE:	11/30/2021
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Crystal Barrientos		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Suspicious death
Staff did not assist resident with prescribed medication administration
Resident's personal property was stolen
Licensee did not make resident’s records available to the responsible party

INVESTIGATION FINDINGS:

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On 11/30/21 Licensing Program Analyst (LPA) Jade Jordan conducted a subsequent visit to deliver the finding regarding allegations above. LPA was met By Assistant Administrator Crystal Barrentios, and the purpose of the visit was explained.

Regarding Suspicious death-
On 01/25/21 R1 was found deceased in room by Administrator. Police Department was contacted, and LA corners arrived at the scene. The facility Administrator contacted Case Carrying LPA the same day. The Information was relayed to management and the Investigation Branch (IB) was informed. The Allegation of Suspicious Death was accepted as an assignment by IB. Within that time of IB’s assignment, a formal complaint was made regarding R1 alleging suspicious death on 04/20/21. Based on IB’s investigation, there is confirmation from the Corners Report that “The cause of death was determined to be accidental with effects of Fentanyl. Fentanyl is a synthetic drug that is 50-100’s more potent than morphine”.

Continued on 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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 3

Control Number 11-AS-20210420152149

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LONG BEACH RESIDENTIAL	FACILITY NUMBER: 198602620
	VISIT DATE: 11/30/2021

NARRATIVE

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According to medication records at the facility, Fentanyl was not a drug that was prescribed to R1 by a physician. Additional records obtained by IB reveal that R1 has a history of Possession/ Arrest of Illegal Substances. Witnesses stated they last seen R1 alive on 01/23/21 and 01/24/21. Records indicate that a pen with white substance was located near R1’s bed, and a prescription bottle with a scratched off label. Based on the information obtained during the course of their investigation, IB concluded that the allegation of suspicious death to be unsubstantiated. Therefore: Although the allegation may have happened, there is not preponderance of evidence that the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

Regarding Staff did not assist with Prescribed Medication Administration.

It was alleged that R1 wasn’t provided assistance with administering their medication throughout their stay at the facility. LPA reviewed the Medical Administration Record (MAR) and R1’s medications were observed to be taken as prescribed except for 2 days listed in which R1 refused. This was documented on the Medication Administration Record (MAR.) Therefore:; Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding Residents Personal property was stolen.

It was alleged that licensee failed to safe keep R1’s Xbox. During the investigation, LPA Observed that the personal property stated by Rp was stored and locked in the administrator’s office for safe keeping. The father of R1 was contacted and he came to retrieve the item. Therefore; Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding Licensee did not make residents records available to the responsible party.

RP stated that she requested from the facility a copy of R1’s admissions Agreement, and Medication Log. The facility only provided R1’s admissions agreement. The facility stated that R1 was not conserved and could not release medical information without consent from R1. As R1 is considered the responsible party, and does not have a Court Appointed Conservator, or POA. During review of resident records, there was not documentation that indicated that the Resident was conserved by person or estate. The Medical Records requested were not a facility created document, and came from the Pharmacy with Residents Name, And Type of Medication. The document was not released due to Hippa. Therefore; Although the allegation may have happened or is valid there is not enough evidence to prove that the violation did or did not occur. Therefore; the allegation is unsubstantiated.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20210420152149

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LONG BEACH RESIDENTIAL	FACILITY NUMBER: 198602620
	VISIT DATE: 11/30/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	An Exit interview was conducted and a copy of this report was provided. No citations were issued during this visit.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3