198602864-4-15-2021-11-AS-AJKK-C2BNFL-20210422102541

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 04/15/2021
Date Signed: 04/15/2021 02:37:16 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 DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2020 and conducted by Evaluator Lourdes Montoya

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200703111939

FACILITY NAME:	SENIOR MANOR CARE		FACILITY NUMBER:	198602864
ADMINISTRATOR:	GRADNEY, ANGELIQUE		FACILITY TYPE:	740
ADDRESS:	2011 SANTA RENA DRIVE		TELEPHONE:	(310) 989-1941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 1	DATE:	04/15/2021
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Angelique Gradney		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident eloped from facility.
Facility did not safeguard resident's cash.

INVESTIGATION FINDINGS:

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On 04/15/2021 at 12:05 pm, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent visit to deliver findings of the above allegations. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via FaceTime with the Licensee/Angelique Gradney.

On 7/10/2020, Licensing Program Analyst (LPA) Kourtney Williams initiated a 10-day complaint investigation for the allegations listed above. LPA conducted a virtual tour of the facility, interviewed a staff, and requested residents and staff rosters.

On 3/21/2021, LPA Lourdes Montoya conducted a virtual tour for health and safety checks, and interviewed staff and residents.

Report continued in LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

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-20200703111939

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
MONTERY PARK, CA 91754

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
	VISIT DATE: 04/15/2021

NARRATIVE

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On 3/25/2021, LPA Lourdes Montoya reviewed the following records: Facility’s Resident roster, Staff roster, Resident #1’s Admission Agreement, Physician’s Report, Appraisal/Needs and Services Plans, and Record of Resident’s Safeguarded Cash Resources.

Investigation Revealed the Following:

Based on record review, Admission Agreement shows Resident #1, the victim, was admitted to the facility on 3/13/2019. Maintenance or supervision of resident cash resources was not added to basic services the facility provides. The Record of Resident’s Safeguard Cash Resources form indicates the facility does not handle resident’s cash resources. According to the Physician’s Report dated 3/4/2021, Resident #1 has mild cognitive impairment but she is able to follow instructions, communicate her needs, and leave the facility unassisted. The Appraisal/Needs and Services Plan indicates Resident #1 is alert, ambulatory with mild cognitive impairment. The plan also states Resident #1 needs daily monitoring and observation.

On 3/21/2021, LPA Montoya contacted the listed facility number (310) 989-1941 and spoke with Staff #8 who denied that she is the administrator or the licensee of the facility. Per LPA's review of LIC 309 dated 1/9/2019, Staff #8 is the Chief Executive Officer of Senior Manor Care, Inc. The department has not received a request from the Licensee to change the chief corporate officer of the organization or corporation to date.

During the virtual tour for health and safety checks on 3/21/2021, LPA Montoya observed residents are well, the home is clean and in order, there are sufficient perishable and non-perishable food supplies, PPE and hygiene supplies were readily available to staff, both on-duty staff are wearing a face covering, and the facility has two caregivers providing care to four residents. LPA observed two side gates are not secured with padlocks, and the facility's surroundings are free of hazard. LPA checked all exit doors for monitoring of residents with memory care needs. LPA observed the main entrance and two sliding doors have working auditory devices; however, the sliding door in bedroom #2 has a non-working auditory device while the sliding door in bedroom #3 does not have an auditory device.

Report continued in LIC 9099C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20200703111939

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
MONTERY PARK, CA 91754

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
	VISIT DATE: 04/15/2021

NARRATIVE

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Resident eloped from facility.

It is alleged that resident eloped from the facility. The Department interviewed residents and staff. Resident #1 stated she does not remember eloping from the facility. Interviews with Residents #2 and #3 revealed they have not heard or observed that a resident eloped from the facility. Residents #4 and #5 did not respond to the interview questions because they had hearing difficulty. Interview with Staff #1 & #2 indicates they have not heard or observed any resident eloped from the facility. Staff #3 stated he was not working yet at this facility when Resident #1 resided in this facility. LPA attempted to interview Staff #4 but could not obtain a statement because he is out of the country, according to Staff #2. Staff #5 and #6 stated they started working at this facility in February 2020 when Resident #1 has already relocated to another facility. They said they could not answer the questions regarding this allegation because they did not meet Resident #1 in this facility. Staff #7 stated she heard that Resident #1 went out but with a caregiver's supervision. LPA attempted to interview Witness #1, who was Resident #1’s former Responsible Party. LPA was informed by Witness #1’s family member that he already passed away. Based on Department’s observations, record review, and interviews, the department did not find sufficient evidence to corroborate this allegation.

Facility did not safeguard resident's cash.

It is alleged that facility did not safeguard resident’s cash. The Department interviewed residents and staff. Residents #1, #2, and #3 denied the facility did not safeguard their cash. They stated the facility does not handle their cash resources. Residents #4 & #5 did not respond to LPA’s questions because they had hearing difficulty. Staff #1, #2 and #7 denied the facility did not safeguard residents’ cash. They stated the facility does not handle residents’ cash resources. LPA attempted to interview Staff #4 but could not obtain a statement because he is out of the country, according to Staff #2. Staff #5 and #6 stated they started working at this facility in February 2020 when Resident #1 has already relocated to another facility. They said they could not answer the questions regarding this allegation because they did not meet Resident #1 in this facility. LPA attempted to interview Witness #1, who was Resident #1’s former Responsible Party. LPA was informed by Witness #1’s family member that he already passed away. Based on Department’s observations, record review, and interviews, the department did not find sufficient evidence to corroborate this allegation.

Based on information gathered, the Department did not find sufficient evidence to support the allegations, “Resident eloped from facility” and “Facility did not safeguard resident's cash”. Although the allegations may have happened or are valid, there is not enough preponderance of evidence to prove the alleged allegations are valid did or did not occur. Therefore, the allegations are "UNSUBSTANTIATED”.

A telephonic exit interview was conducted with Licensee Angelique, and an electronic copy was provided via email for signature.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC9099 (FAS) - (06/04)

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