198602864-7-5-2022-11-AS-JHAD-CGRRME-20220728130834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 11/16/2021
Date Signed: 07/05/2022 11:55:10 AM

Unsubstantiated

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
11/10/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20211110150940

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:	11/16/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	ADMINISTRATOR STEVEN GRADNEY		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident(s) not administered medication as prescribed by physician.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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On 11/16/2021 around 09:00am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Steven Gradney.

The Investigation consisted of the following: On 11/16/2021 LPA Calderon interviewed S1 for complaint. On 11/16/2021 LPA Calderon interviewed S2-S3 for complaint. On 11/16/2021 LPA Calderon attempted to interview R1-R5, only R1 – R2 could answer any questions due to dementia. On 11/16/2021 LPA Calderon reviewed MAR for R1-R5, reviewed admission agreement for facility and reviewed S2-S3 employee files. LPA Calderon reviewed R2 admission agreement and resident file for complaint. On 11/16/2021 LPA Calderon and Administrator Gradney toured the physical plant.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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-20211110150940

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: 11/16/2021

NARRATIVE

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Allegation 1: Resident(s) not administered medication as prescribed by physician.

On 11/16/2021 LPA Calderon interviewed S1 for complaint, S1 states that S1 was not aware of any issues with S1 facility and states that if there are any issues with the care of S1 residents or the facility, S1 will take care of any issues the same day. On 11/16/2021 LPA Calderon interviewed S2-S3 both staffs state that they give the right medication on time and in the right amount and update the residents MAR. Staff states that they follow the prescribed doctors’ orders for resident’s medication and if there is a change, or different amount they update the residents MAR. On 11/16/2021 LPA Calderon interviewed R1-R2, R1 states that staff gives the right medication but from time to time are late with the giving the medication, but has no issues with the care given, R2 states that there are no issues with the medication given. On 11/16/2021 LPA Calderon reviewed MAR for R1-R5, and there does not appear to be any issues with the documentation for residents’ medications and all times and dates are filled out for the past 5 months.

Allegation 2: Facility is in disrepair.

On 11/16/2021 LPA Calderon interviewed S1-S3 and all state no issues or concerns with the facility and there are no safety issues. On 11/16/2021 LPA Calderon interviewed R1-R2, but state that the facility is safe, well maintained and they have no issues with the facility or living in this home. On 11/16/2021 LPA Calderon and Administrator S1 toured the facility, LPA Calderon checked electric outlets and the physical plant. There does not appear to be any issues with the facility and the facility is well maintained and LPA Calderon could not find any issues.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of residents not administered medication as prescribed by physician, and facility is in disrepair is found to be UNSUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report was provided to the Administrator (Steven Gradney).

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC9099 (FAS) - (06/04)

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