198602864-12-1-2021-11-AS-AJKK-C9U5N7-20211218190552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 11/23/2021
Date Signed: 12/01/2021 10:59:39 AM

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
11/19/2021 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20211119150306

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: 5	DATE:	11/23/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	STEVEN GRADNEY		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are not assisting resident with managed incontinence.

INVESTIGATION FINDINGS:

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On 11/23/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced 10day complaint visit at this facility. LPA met with Staff Gloria Somintac and explained the purpose of today's visit is to gather information of the allegation mentioned above. Administrator Steven Gradney arrived later and joined the visit.

The investigation consisted of the following: LPA inquired questions relevant to the nature of the complaint. LPA Lourdes Montoya conducted interviews with Staff (S1-S3) and resident (R1) on 11/23/2021. LPA was unable to interview Residents (R2-R5) because R2 left during the visit, R3 has a hearing problem, R4 was asleep and R5 has a dementia. A tour of the facility’s outside and inside grounds was conducted. LPA obtained residents’ (R1) service records, residents’ (R2-R5) physician’s reports; facility roster, and staff roster.

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: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

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-20211119150306

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: 11/23/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff are not assisting resident with managed incontinence.

It is alleged facility staff are not assisting resident with managed incontinence.The complainant reported facility care providers are not changing the resident's diaper in a timely manner. Based on record review, Resident's (R1) physician report shows she has no bowel and bladder impairment and she is able to manage her own toileting needs. Interview with R1 and staff (S2-S3) revealed R1 is not incontinent but because she is unable to get up and walk independently, she uses diaper for urination and defecation. Therefore, she needs assistance in changing her diaper. R1 stated in interview that she waits for ten (10) to fifteen (15) minutes for staff to change her diaper and sometimes when staff are too busy, she waits for thirty (30) minutes. Nevertheless, R1 disclosed she thinks the wait time is reasonable. R1 revealed staff are providing quality care and she is happy living in this facility. Based on LPA's record review, R3, R4 and R5 are unable to care for their own toileting needs but LPA was unable to obtain information about their incontinence needs because LPA was unable to interview them. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, "Staff are not assisting resident with managed incontinence" did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited and exit Interview was conducted with Administrator Steven Gradney. LPA Montoya was unable to furnish a hard copy of the report due to a technical issue. A copy of the report was emailed to Administrator Steven Gradney.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC9099 (FAS) - (06/04)

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