198603220-7-16-2021-11-AS-JHAD-C5LU5X-20210805151726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603220
Report Date: 07/16/2021
Date Signed: 07/16/2021 12:49:50 PM

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
09/14/2020 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200914144030

FACILITY NAME:	CITY VIEW LA, LLC		FACILITY NUMBER:	198603220
ADMINISTRATOR:	ROSIE JULINEK		FACILITY TYPE:	740
ADDRESS:	515 N LA BREA AVE		TELEPHONE:	(323) 938-3128
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90036
CAPACITY:	166	CENSUS: 52	DATE:	07/16/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Mary lou Jeynty, Business Office Manager		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident suffered from malnutrition while in care
Resident suffered from dehydration while in care
Resident sustained serious injury while in care resulting in hospitalization
Resident was left unsupervised for extended period of time after falling
Facility failed to seek resident timely medical attention

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Marylou Jeynty, Business Office Manager.

The investigation consisted of following: On 09/14/2020, LPA Williams conducted the initial 10-day virtual visit, due to situations surrounding the Corona Virus Disease (Covid 19.) LPA Williams conducted interviews with Wellness nurse, John McMahon. LPA Williams also obtained the following documents: The service request, Facility roster, Staff roster, R#1 entire file (Needs and Services Plan, Physician’s Report, Medication administration log, Admissions agreement, Physician’s faxed documentation.) the complaint was accepted by CCLD IB Investigation Unit. On 09/14/2020, the case was assigned to IB Investigator Lorraine Patterson. On 12/23/20, 12/28/20, & 12/29/20, IB Investigator conducted interviews with staff, RP, and Ombudsman Amanda Shaon. IB Investigator also requested the following documents: R#1 Medical Reports from Kaiser Hospital.

Unsubstantiated

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: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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-20200914144030

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: CITY VIEW LA, LLC	FACILITY NUMBER: 198603220
	VISIT DATE: 07/16/2021

NARRATIVE

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Based on the IB investigators investigation, the investigation revealed the following:

For Allegation 1 –Resident suffered from malnutrition while in care. Resident suffered from dehydration while in care. IB investigator interview’s with Wellness Director, stated that R#1 nutrition was a concern. R#1 always refused her food, R#1 was on a liquid diet and sometimes refused the liquid food(Boost) stating she was fine and that’s how R#1 looked. Interviews with care givers, also stated that R#1 refused to eat and always stated R#1 was fine and not hungry to leave R#1 alone. R#1 records revealed a significant health history to mild protein caloric intake malnutrition. Loss of appetite, abnormal weight loss, and anorexia which may have been contributing factors in the alleged. IB investigators review of R#1 medical records, also read that R#1 had a well documented on-going concern with R#1 malnutrition (diet) and Dehydration. The interviews conducted and records reviewed by IB Investigator Patterson did not concur with the above allegation.

Allegation #2 - Resident suffered from dehydration while in care. IB investigator interview’s with Wellness Director, stated that R#1 nutrition was a concern. R#1 always refused her food, R#1 was on a liquid diet and sometimes refused the liquid food, stating she was fine and that’s how R#1 looked. Interviews with care givers, also stated that R#1 refused to eat and always stated R#1 was fine and not hungry to leave R#1 alone. R#1 records revealed a significant health history to mild protein caloric intake malnutrition. Loss of appetite, abnormal weight loss, and anorexia which may have been contributing factors in the alleged. IB investigators review of R#1 medical records, also read that R#1 had a well documented on-going concern with R#1 malnutrition (die) and Dehydration. The interviews conducted and records reviewed with the above allegation.

Allegation #3 - Resident sustained serious injury while in care resulting in hospitalization. IB Investigator interviewed Wellness Director and Care givers, stated that when R#1 was checked on, and visually observed and spoken to R#1 within the approximate hour of R#1 un-witnessed fall, while being at R#1 normal baseline. 911 was called and R#1 transported to hospital. R#1 CT head scan revealed a very small parenchymal hemorrhagic contusion of the left frontal lobe. Ct brain showed stable bleed. R#1 was discharged in stable condition. The interviews conducted and records reviewed by IB Investigator Patterson did not concur with the above allegation.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200914144030

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: CITY VIEW LA, LLC	FACILITY NUMBER: 198603220
	VISIT DATE: 07/16/2021

NARRATIVE

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Allegation #4 - Resident was left unsupervised for extended period of time after falling. IB Investigator interviewed Wellness Director and Care givers, stated that when R#1 was checked on, and visually observed and spoken to R#1 within the approximate hour of R#1 un-witnessed fall, while being at R#1 normal baseline. R#1 was checked on during the night by nocturnal staff and was found to be asleep. Medical technician also checked on R#1 that early morning before breakfast. The morning staff (care giver) began their rounds and checked on R#1 around 08:00am and R#1 was laying down on her bed and advised care giver she did not want breakfast. The fall must of occurred sometime after her visit (few minutes later,) because they informed her of R#1 fall. The interviews conducted and records reviewed by IB Investigator Patterson did not concur with the above allegation.

Allegation #5 - Facility failed to seek resident timely medical attention. IB Investigator interviewed Wellness Director and Care givers, stated that when R#1 was checked on, and visually observed and spoken to R#1 within the approximate hour of R#1 un-witnessed fall, while being at R#1 normal baseline. They continued to state that 911 was called immediately. The medical records obtained from hospital, support R#1 arrival to the ER approximately 10:14 hours, due to a fall complaint and the hospital flow sheets reported no signs or suspicion of abuse or neglect and the facility did not fail to seek untimely medical attention. The interviews conducted and records reviewed by IB Investigator Patterson did not concur with the above allegation.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted with Marylou Jeynty, Business Office Manager and a hard copy was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

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