198602864-6-19-2023-11-AS-RORN-CTHL2L-20230707082229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 06/18/2023
Date Signed: 06/19/2023 10:06:22 AM

Substantiated

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
04/27/2023 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230427112028

FACILITY NAME:	SENIOR MANOR CARE		FACILITY NUMBER:	198602864
ADMINISTRATOR:	STEVEN GRADNEY		FACILITY TYPE:	740
ADDRESS:	2011 SANTA RENA DRIVE		TELEPHONE:	(310) 989-1941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 6	DATE:	06/18/2023
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Gloria Somintac, House Manager		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff failed to provide resident records, medical records, x-rays, color and/or black and white photographs and billing records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Gloria Somintac, House Manager.

The investigation consisted of following: Interviews and Record reviews. On 05/05/23, LPA Soto interviewed S#1 – S#3, R#2 – R#7. LPA requested and received the following documents on 05/05/23: Resident Roster, Staff Schedule. LPA also requested copy of R#1 file, Admissions agreement, ID/Emergency information, copy of 1st rent receipt, Preplacement appraisal information, Appraisal/Needs and Services Plan, Resident Appraisal, Personal Property page, Mars (June, July, August 2021) Consent for emergency medical treatment, Physician’s report, and Hospital records (Newport hospital and legend home health.) Witness provided copy of request and delivered tracking notice.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2023

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-20230427112028

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: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
	VISIT DATE: 06/18/2023

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following.

Allegation – Staff failed to provide resident records, medical records, x-rays, color and/or black and white photographs and billing records. Interviews with S#1 – S#3, communicated that they did not receive any request for records for resident. S#1 communicated that S#1 has been working at the facility a little over a year. They did not receive any request for records by mail or any other way. S#2 & S#3, communicate that S#2 had been in vacation, so S#2 did not see or get any request for records for resident. S#3 does not supervise facility, so, S#3 did not have knowledge of ever receiving any request for records for resident. LPA reviewed records provided by witness, where it demonstrates request package was delivered by United Parcel Services on 04/19/23 to facility address. Facility failed to provide copy of requested file within 2 business day as per TITLE 22 regulations. LPA’s records review did concur with the above allegation.

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Gloria Somintac, House Manager and a hard copy of report was provided along with Appeal rights.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230427112028

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: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/03/2023 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	To have prompt access to review all of their records and to purchase photocopies of their records.....This was not as evidence by: based on facility failing to provided requested records within 2 business day as per TITLE 22 regulations.	1 2 3 4 5 6 7	Adminsitrator to provide complete file to attorney. Send proof of delivered file to LPA.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2023

LIC9099 (FAS) - (06/04)

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