198602864-6-19-2023-11-AS-JHAD-CUBQFC-20230802120743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 06/18/2023
Date Signed: 06/19/2023 10:06:44 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
05/16/2023 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230516150239

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:	04:15 PM
MET WITH:	Gloria Somintac, House Manager		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff failed to supervise resident resulting in the resident wandering away from the facility.

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. LPA Soto conducted interviews with S#1 - S#3, R#1 - R#6, and W#1. The LPA also requested copies of the following documents: Resident roster and Staff roster. Administrator never provided Incident report and/or Incident Report # from LASD-LOMITA.

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)

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Control Number 11-AS-20230516150239

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 – Facility staff failed to supervise resident resulting in the resident wandering away from the facility. Interviews with S#1 – S#2, communicated that they were not at the facility at the time resident left the facility unsupervised. S#1 wasn’t working at the facility at the time of the incident. S#2 had the day off and wasn’t at the facility at the day of the incident. S#3 communicated that S#3 did not recall what exactly happened the day the resident left the facility unsupervised. S#3 recalled that resident was a wanderer. The day resident left the facility unsupervised they had 2 new care givers working that day, they are no longer working at the facility. He believed one was in the garage doing laundry and the other care giver was helping a resident. They heard the egress signal go off and they both went to see who had opened the door. S#3 believes they checked the facility and found that one resident was no longer at the facility. They walked around the neighborhood, local stores, and restaurants looking for the resident. They could not locate resident, so they called 911 to report resident missing. When LASD arrived at the facility take the report, they informed S#3 that they had found resident, resident had gone back to resident original home. Apparently, resident had gotten into an uber and ended at resident original home. No one knows how resident was able to get an uber and give their address to have them take resident there. Interview with witness communicated that W#1 was outside of their home when they saw resident pull up in front of their home. W#1 recognized resident and was asked by UBER driver, “If they knew the passenger” and W#1 told them yes. W#1 contacted resident’s family and kept resident with them until resident’s family came to get resident. Interviews conducted 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 deficiencies and issued a citations.

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)

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Control Number 11-AS-20230516150239

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 A 07/01/2023 Section Cited CCR 87211(a)(D)	1 2 3 4 5 6 7	Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This was not met as evidence by: based on resident wandered out the facility unsupervised	1 2 3 4 5 6 7	Administrator to conduct a training session on how to avoid having resdient leave the facility without supervision. Send training and log with signatures to LPA.
	8 9 10 11 12 13 14	which poses a health and safety risk for all persons in care	8 9 10 11 12 13 14
Type A 07/01/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).	1 2 3 4 5 6 7	Administrator to conduct a training session on how to avoid having resdient leave the facility without supervision. Send training and log with signatures to LPA.
	8 9 10 11 12 13 14	This was not met as evidence by: Based on based on resident wandered out the facility unsupervised. Which poses a health and safety risk for all persons in care	8 9 10 11 12 13 14

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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