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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602866
Report Date: 04/01/2022
Date Signed: 04/04/2022 03:39:40 PM

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
07/03/2020 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20200703110054
FACILITY NAME:SENIOR MANOR CARE IIFACILITY NUMBER:
198602866
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1851 REDONDELA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 4DATE:
04/01/2022
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Charles AbadTIME COMPLETED:
04:07 PM
ALLEGATION(S):
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Staff does not provide adequate food service for residents.
Residents care needs are not being met.
Residents are not being provided activities.
Facility's ramp poses a hazard to residents.
Staff not informing resident's authorized representatives of incidents involving resident.
Staff unable to communicate with resident due to language barrier.
INVESTIGATION FINDINGS:
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On 04/01/22 Licensing Program Analyst (LPA) Jade Jordan conducted a subsequent to conclude investigation complaint received on 07/03/20, which was previously initiated virtually. Lpa was met by House Manger Charles Abad, and the purpose of the visit was explained.

Investigation Consisted of the following: Physical Plant Tour, Record Review of Admissions Agreements, Physician Report, Needs and Services, Resident Interviews, Staff Interview


****** Continued on 9099 C*************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
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 6
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
07/03/2020 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20200703110054

FACILITY NAME:SENIOR MANOR CARE IIFACILITY NUMBER:
198602866
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1851 REDONDELA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: DATE:
04/01/2022
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Charles AbadTIME COMPLETED:
04:07 PM
ALLEGATION(S):
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Residents are not provided hygiene products.
INVESTIGATION FINDINGS:
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On 04/01/22 Licensing Program Analyst (LPA) Jade Jordan conducted a subsequent to conclude investigation complaint received on 07/03/20, which was previously initiated virtually. Lpa was met by House Manger Charles Abad, and the purpose of the visit was explained.
Investigation Consisted of the following: Physical Plant Tour, Record Review of Admissions Agreements, Physician Report, Needs and Services, Resident Interviews, Staff Interview.
Regarding Allegation- Residents are not provided hygiene products.
RP stated that R1 is not being provided Toothpaste, bodywash, special dental care, deodorant, and occasionally toilet paper. Rp stated that these things are being provided to R1 from r1’s family.
Interviews Conducted with R2 stated that she is not being provided toothpaste. House Manager stated that she is conserved through the state and waiting for funding.
“Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) us found to be SUBSTANTIATED. California Code Of Regulations, (Title 22, Division6, Chapter #8), are being cited on the attached LIC 9099 D.”)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20200703110054
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 II
FACILITY NUMBER: 198602866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2022
Section Cited
CCR
87307A3
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87307A(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of..
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Facility will Provide proof of basic toothbrush and toothpaste for resident and will send an email photo to : Jade.Jordan@dss.ca.gov by POC due date of 04/04/22
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 This standard was not met as evidenced by: Based on LPA interview Resident 3 stated that they did not have a toothbrush or toothpaste, and was not provided one by the facility.
This poses a potential health, safety and personal rights risk to residents in care
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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: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20200703110054
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 II
FACILITY NUMBER: 198602866
VISIT DATE: 04/01/2022
NARRATIVE
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Regarding Allegation: Staff does not provide adequate food service for residents.

RP stated that R1 has a modified diet prescribed by the doctor due to high blood pressure, and diabetes.

Rp states that the facility serves high salt food content such as soups, lots of Pork, and does not serve fresh fruits or vegetables. Record Review of R1 revealed that a modified diet was indicated of liquid, but did not indicate by a physicians prescription perimeters of food other than liquid. On 04/01/22 during physical tour LPA observed Fresh foods such as cabbage, lettuce, tomatoes, onion, bananas, orange, apples, celery, bell pepper, bread, snap peas, milk, apple sauce, oatmeal, cantaloupe, and some chicken, pork, frozen veggies, in the freezer. Record Review of other clients in care physician’s report revealed that no other residents have a modified diet.

Therefore, Based on LPA’s Observation, Record Review, and Interviews the Department Finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

Regarding the Allegation: Resident Care Needs are not being Met

RP stated that the facility’s female staff did not want to help assist R1 with toileting and change of diaper, because staff felt it was inappropriate, in turn causing r1 to have to wait until a male staff was available. House Manager stated that they respect the privacy of residents, and that if resident feels comfortable either sex of a care giver they will move forward with assisting. LPA interview residents r2-r3. R2, and R3 stated that they don’t have any issue with staff assisting with their needs. R2, and R3 stated that they feel comfortable with male and female caregiver’s assistance and receive both.

Based on LPA’s Observation, Record Review, and Interviews the Department Finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20200703110054
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 II
FACILITY NUMBER: 198602866
VISIT DATE: 04/01/2022
NARRATIVE
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Regarding the allegation – Residents are not being provided activity’s

Reporting Party stated that activities are not being provided, just TV’s. The compliant was made during Covid-19 Pandemic in which social distancing was recommended, and limited interaction with others due to the virus. Interviews with House Manger revealed that activities that are being offered at this time are walks outside, Gardening, and the facilities has board games. 3 of 4 residents are Non ambulatory, and choose not to participate. Interviews with Resident 2 (R2) revealed. That they Garden and go for walks. LPA observed a Bowling Game in the dining room, and outside garden area.

Based on Interviews, and observation, Record Review the Department finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

Regarding Allegation: Facility's ramp poses a hazard to residents

LPA observed virtually that the ramp was in good condition on 07/09/20 that the front ramp was in good condition and had been repaired prior to the complaint. LPA Observed on 04/01/22 during physical tour, that the Ramp in question was still in good condition.

Therefore; the department finds that

“Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

***** Continued on 9099 C****************

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20200703110054
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 II
FACILITY NUMBER: 198602866
VISIT DATE: 04/01/2022
NARRATIVE
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Regarding Allegation: Staff not informing resident's authorized representatives of incidents involving resident.

Reporting Party stated that they were not notified of a fall, that did not result in hospitalization. Interviews with staff stated that in a life or death situation or hospitalization the proper authorities such as 911 is notified, Administrator, and responsible party. Responsible parties will be notified if the facility staff observes things on a resident that maybe detrimental to their health. Interviews with residents R2, And R3 care generally stated that they have no family or friends to be contacted in case of emergency. The witnessed fall from R1 did not result in injury or hospitalization.

Therefore: Based on Record Review, observation, and Interviews the Department finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

Regarding Allegation: Staff unable to communicate with resident due to language barrier

Interviews with House Manger stated that all Caregivers can speak English, as well as all residents in care who are verbal.

Interviews with Resident 2, and 3 Generally stated that they are able to communicate with staff, and have their needs met. During the physical visit LPA observed Caregivers communicating effectively with residents in care.

Therefore; Based on Record Review, observation, and Interviews the Department finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An Exit Interview Conducted and copy of this report was provided

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6