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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603047
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:31:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2024 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20241016172930
FACILITY NAME:GREEN MEADOWS HOME IIFACILITY NUMBER:
198603047
ADMINISTRATOR:OM, RAKSMIEFACILITY TYPE:
735
ADDRESS:24225 POSTMASTER AVETELEPHONE:
(310) 871-4219
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY:4CENSUS: 4DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:ADMINISTRATOR WATNEY CHHUONTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Facility staff interfered with resident’s sleep
Facility staff denied resident access inside the facility
INVESTIGATION FINDINGS:
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7
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Green Meadows Home 2 Facility on 10/23/2024 and was greeted by Administrator Watey Chhuon (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

The investigation consisted of the following: LPA Calderon interviewed Administrator (S1), staff (S1-S3), residents (R1-R4) and W1. LPA Calderon requested and reviewed copies of the following: Physician Report (dated 02/09/2024), Needs and Services Plan (dated 07/01/2024), incident report (dated 10/11/2024), admission agreement (dated 09/30/2021), LIC500.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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 5
Control Number 11-AS-20241016172930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GREEN MEADOWS HOME II
FACILITY NUMBER: 198603047
VISIT DATE: 10/23/2024
NARRATIVE
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Regarding Allegation #1: Facility staff interfered with resident’s sleep.

It is being alleged that facility staff interfered with R1 sleep waking R1 at 8am. LPA Calderon toured the facility with S1. During tour of the facility LPA noted the facility was clean and one staff working. LPA Calderon inspected residents’ room and found the rooms to be in line. 3 out 3 staff indicate that S3 did in fact wake R1 up around 8am a few times. R1 states that S3 woke R1 up around 8am more than a few times. 3 out of 4 residents indicate that S3 did wake them up due to going to day program. W1 indicates that S3 woke up R1 around 8am many times a week.

Regarding Allegation #2: Facility staff denied resident access inside the facility. It is being alleged that facility staff locked R1 outside of the home. LPA Calderon toured the facility and noted all doors had locks and R1 room door lock worked. LIC 500 indicates S3 works 3 days a week and there does not appear to be another staff that works the same shift. 3 out of 3 staff indicate that S3 did in fact ask R1 to wait outside of the home while S3 was taking other residents to day program. 3 out of 3 staff indicate that S3 did lock the front door preventing R1 from entering the facility. R1 indicates that S3 did ask R1 to wait outside of the home while S3 was taking other residents to day program. R1 indicates that S3 locked the front door and prevented R1 from entering the facility. 3 out of 4 residents indicate that they go to day program and have never been locked out of the facility. W1 indicates that S3 locked R1 outside of the facility while S3 was taking resident to day program.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegations of “facility staff interfered with residents sleep”, facility staff denied resident access inside the facility” is found to be SUBSTANTIATED.



Deficiencies cited during today's visit.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Watey Chhuon S1.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20241016172930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GREEN MEADOWS HOME II
FACILITY NUMBER: 198603047
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights(a)Except for children’s residential facilities...(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule...This requirement was not met as evidenced by
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Licensee will provide additional training to staff regarding personal rights of residents in care and will email LPA Calderon with training sign up sheet by POC due date.
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Based on records reviewed and interviews conducted the licensee failed to ensure R1 was not woken R1 perfered waking time. This poses a Safety risk to residents in care.
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Type B
12/06/2024
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights(a)Except for children’s residential facilities...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by
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Licensee will provide additional training to staff regarding personal rights of residents in care and will email LPA Calderon with training sign up sheet by POC due date.
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Based on records reviewed and interviews conducted the licensee failed to ensure R1 was not left outside the facility locked out. This poses a Safety 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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2024 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20241016172930

FACILITY NAME:GREEN MEADOWS HOME IIFACILITY NUMBER:
198603047
ADMINISTRATOR:OM, RAKSMIEFACILITY TYPE:
735
ADDRESS:24225 POSTMASTER AVETELEPHONE:
(310) 871-4219
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY:4CENSUS: 4DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:ADMINISTRATOR WATNEY CHHUONTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff spoke inappropriately to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Green Meadows Home 2 Facility on 10/23/2024 and was greeted by Administrator Watey Chhuon (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

The investigation consisted of the following: LPA Calderon interviewed Administrator (S1), staff (S1-S3), residents (R1-R4) and W1. LPA Calderon requested and reviewed copies of the following: Physician Report (dated 02/09/2024), Needs and Services Plan (dated 07/01/2024), incident report (dated 10/11/2024), admission agreement (dated 09/30/2021), LIC500.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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 5
Control Number 11-AS-20241016172930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GREEN MEADOWS HOME II
FACILITY NUMBER: 198603047
VISIT DATE: 10/23/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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Regarding Allegation #1: Facility staff spoke inappropriately to resident.

It is being alleged that the facility staff made fun of R1 and yelled at R1. LPA Calderon toured the facility and noted R1 room door had a lock that worked. 3 out of 3 staff indicate that S3 has never yelled or made fun of R1 actions. R1 indicates that R1 was in R1 room and was having fun when S3 walked in R1 room and told R1 to stop what R1 was doing. R1 indicates that S3 yelled at R1 many times. 3 out of 4 residents indicate that staff has never yelled or spoke to residents inappropriately. W1 indicates that S3 did yell at R1 and spoke to R1 in the wrong way.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “facility staff spoke inappropriately to resident” is found to be UNSUBSTANTIATED.



No deficiencies cited during today's visit.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Watey Chhuon S1.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5