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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602620
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:34:52 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/30/2024 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20240730091219
FACILITY NAME:LONG BEACH RESIDENTIALFACILITY NUMBER:
198602620
ADMINISTRATOR:CRYSTAL BARRIENTOSFACILITY TYPE:
735
ADDRESS:4201 EAST 10TH STREETTELEPHONE:
(562) 433-2455
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY:49CENSUS: 49DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Marinel A. LunaTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Staff dispensed discontinued medication to resident.
Staff did not ensure the safety of food served to residents.
INVESTIGATION FINDINGS:
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On 08/01/24 at 09:15 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Administrator (A1) Marinel Amanda Luna as the purpose of today’s visit was explained.
The investigation consisted of the following: On 08/01/24 LPA requested the following documents: staff and client rosters, medication training verification for staff, menu for July 2024, and food handler certificate for A1 and S2. LPA also obtained the following documents for C1: Facesheet, pre-appraisal, physicians report, physicians orders, needs and service plan, admission agreement and MAR(s) for May-July 2024. On 08/01/24 from 9:45 am-10:30 am LPA conducted interviews with Clients # 1-5 (C1-C5), from 10:35am- 11:45 am LPA interviewed A1, staff #1-4 (S1-S4), and witness #1 (W1). On 08/01/24 LPA conducted review of medication administration records, and toured the facility as a health and safety check.
The investigation revealed the following:
Allegation: Staff dispensed discontinued medication to resident.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 2
Control Number 11-AS-20240730091219
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620
VISIT DATE: 08/01/2024
NARRATIVE
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It is being alleged that facility staff are administering a medication that has been discontinued. On 08/01/24 at 10:35 am LPA interviewed A1 regarding the allegation above, A1 denied the allegation above and reported that the discontinued medication has not been administered. Per A1 when any medication is discontinued, that medication is taken out of medication cycle. A1 continued to report that when a medication is discontinued a medication destruction takes place and the medication is dissolve as Bonita pharmacy provides facility with a dissolution pack. Between 10:35am- 11:45 am LPA interviewed S1-S4 regarding the allegation above, 1 of 4 staff interviewed reported medications are administrators per Doctors orders and any discontinued medications are labeled and destructed per pharmacy's procedures. 3 of 4 staff interviewed reported being unaware of medication procedures. On 08/01/24 between 9:45 am-10:30 am LPA interviewed C1-C5 regarding the allegation above, 1 of 5 clients interviewed reported concerns that discontinued medications were administered which resulted in a hospitalization. 4 of 5 clients interviewed denied the allegation above and reported having no concerns regarding medications. On 08/01/24 at 12pm LPA interviewed W1 regarding the allegation above, per W1 W1 reviewed hospital discharge summary for July 2024 and there was no order placed by the Doctor for medication in question upon hospital discharge. On 08/01/24 LPA conducted a medication review for May-July 024 and did not observe the medication in question listed on the MAR nor was the physical medication observed.

Allegation: Staff did not ensure the safety of food served to residents.
It is being alleged that facility staff is serving expired food. On 08/01/24 at 10:35 am LPA interviewed A1 regarding the allegation above, A1 denied the allegation above and reported that all food at the facility is dated with expirations dates when it arrives from Costco. Between 10:35am- 11:45 am LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported all food is labeled with expiration date. On 08/01/24 between 9:45 am-10:30 am LPA interviewed C1-C5 regarding the allegation above, 1 of 5 clients interviewed reported being serve a cold meal when the meal should of been warm. 4 of 5 clients interviewed denied the allegation above and reported having no concerns regarding the meals being served at the facility. On 08/01/24 LPA conducted a tour of the facility kitchen and pantry and observed all proteins, can goods, cereals, frozen foods and drinks to be labeled with expiration dates, LPA did not observe any expired food upon tour.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Administrator, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2