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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603220
Report Date: 10/03/2024
Date Signed: 10/03/2024 01:01:05 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
06/20/2024 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20240620162835
FACILITY NAME:CITY VIEW LA, LLCFACILITY NUMBER:
198603220
ADMINISTRATOR:HIRSCH, RENAFACILITY TYPE:
740
ADDRESS:515 N LA BREA AVETELEPHONE:
(323) 938-2131
CITY:LOS ANGELESSTATE: CAZIP CODE:
90036
CAPACITY:166CENSUS: 101DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Vanita HarrisTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff did not notify authorized representative of resident's fall
Staff did not seek timely medical care for resident
Staff lost resident's dentures
INVESTIGATION FINDINGS:
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On 10/03/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to deliver findings for the above complaint. LPA met with Business Manager, Vanita Harris, and the purpose of today’s visit was explained.
During a subsequent visit conducted on 07/18/24, Licensing Program Analysts (LPAs), Wendy Gibbs and Deborah Lee, met with Executive Director, Mendy Ginsburg and the purpose of the visit was explained. During that visit, LPA toured the facility, interviewed Staff (S5-S7), and interviewed Residents R2-R11.
During LPA’s initial visit on 06/26/24, LPA Wendy Gibbs, conducted an unannounced visit to the facility. LPA met with Executive Director, Rena Hisch, and Regional Executive Director, Mendy Ginsburg, and the purpose of the visit was explained. During that visit, LPA toured the facility, interviewed Staff (S1-S4), and received documents pertinent to the investigation. The documents received and reviewed include Staff Roster, Resident Roster, Resident Physician’s Report, Needs and Service Plan, Resident Progress Notes, Admission Agreement, Safeguard of valuable, and Special Incident Reports (SIR) regarding falls and refusal
(1)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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 6
Control Number 11-AS-20240620162835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CITY VIEW LA, LLC
FACILITY NUMBER: 198603220
VISIT DATE: 10/03/2024
NARRATIVE
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of additional medical care.
The investigation revealed the following:
Allegation: Staff did not notify authorized representative of resident’s fall
The complaint allegation alleges that the resident’s responsible person was not notified of the residents fall when it occurred and was notified in an email the following day.
During review of resident R1’s Progress Notes dated on 06/16/24, LPA observed R1 was found on the floor by a caregiver, 911 was called, and the POA was called. It was indicated in the Progress Notes the POA told facility staff to cancel 911. Additionally, below the note it was indicated R1’s Responsible Person was notified as well as the Primary Care Physician. The Notes indicate on 06/19/24, R1’s Responsible Person refused to sign the Refusal of 911 Service, Transport and/or Evaluation form. Additionally, during file review LPA observed on the Resident Roster, Resident Progress Notes, Admission Agreement, and Identification and Emergency Information indicates who R1’s Responsible Person is.
During an interview with R1’s responsible party, stated they were not informed of R1’s fall till they came to the facility on 06/17/24. During the interview the responsible party stated they knew about the fall before the facility informed them because the facility staff called their sibling. Additionally, the responsible party stated they refused to sign the Refusal Form because they were never informed of 911 being called or canceled and they confirmed with their sibling that the facility staff did not mention anything about calling 911.

(2) Continued on LIC9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20240620162835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CITY VIEW LA, LLC
FACILITY NUMBER: 198603220
VISIT DATE: 10/03/2024
NARRATIVE
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During interviews with Staff S1-S7, were asked when a resident’s responsible party is notified of a residents fall, seven (7) out of seven (7) stated the responsible party is notified right after 911 is called.
During interviews with Residents R2-R11, were asked if the facility staff notify their responsible person or family if they experience a fall, or are not feeling well, six (6) out of ten (10) stated yes, their family is notified if they have a fall or are not feeling well. Two (2) of the residents interviewed stated they have not experienced a fall or incident requiring their responsible party to be notified, and one (1) resident stated they do not report their falls to the facility staff.
Allegation: Staff did not seek timely medical care for resident
The complaint allegation alleges that residents responsible party denied 911.
During file review, LPA observed R1’s Progress Notes dated on 06/16/24, LPA observed R1 was found on the floor by a caregiver, 911 was called, and the POA was called. It was indicated in the Progress Notes the POA told facility staff to cancel 911. Additionally, below the note it was indicated R1’s Responsible Person was notified as well as the Primary Care Physician. LPA observed in the notes that no injury was noted, R1 had no complaints of pain or discomfort, and staff conducted frequent checks.
During interviews with R1’s Responsible Party, stated facility staff called their sibling, who is listed as an Other Person to be Notified In Emergency and not person indicated as the Responsible Person. Additionally, the responsible party stated they were asked to sign a Refusal of 911 Service, Transport and/or

(3) Continued on LIC9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20240620162835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CITY VIEW LA, LLC
FACILITY NUMBER: 198603220
VISIT DATE: 10/03/2024
NARRATIVE
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Evaluation form and they refused to sign the Refusal Form because they were never informed of 911 being called or canceled. R1’s Responsible Party called and confirmed with their sibling that the facility staff did not mention anything about calling 911.
During interviews with Staff S1-S7, were asked when is medical personnel called or a resident transferred to the Emergency Room due to a fall, seven (7) out of seven (7) stated 911 is called when the resident is experiencing pain, has an injury, hits their head, are unresponsive, unable to get up, or depending upon the medications they are on that might cause bleeding.
During interviews with Residents R2-R11, were asked if they receive medical assistance when needed, nine (9) out of ten (10) stated they receive medical assistance when needed.

Allegation: Facility did not safeguard residents personal belongings/Staff lost resident’s dentures

The complaint allegation alleges that the facility staff threw out a resident’s dentures.

During file review LPA reviewed the Resident R1’s Client/Resident Personal Property and Valuables (LIC621) form and observed dentures listed under personal property. Additionally, LPA observed on the Physician’s Report and Needs and Service Plan indicates that R1 has dentures. On the Admission Agreement, LPA

(4) Continued on LIC9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20240620162835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CITY VIEW LA, LLC
FACILITY NUMBER: 198603220
VISIT DATE: 10/03/2024
NARRATIVE
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observed on page 16 under Your Property Right and Obligations section C. Damage to Your Property states the facility is not responsible “unless the loss or damage was caused by our negligence or that of our employees.” Additionally, in the Admission Agreement under the Shared Risk Agreement states in section E. Risk of Property Loss 1. “resident and their representatives accept and acknowledge that personal items, including but not limited to items of clothing, prescription glasses, dentures, or hearing aids, may be lost or misplaced. The Community accepts no responsibility for the loss of a resident’s personal property, unless due to the negligence of the Community or that of its employees.” The Admission Agreement was sign by R1’s Responsible Party on 04/29/22, under the statement “by signing this Shared Risk Agreement, you agree and acknowledge that the Community has informed you that it does not and cannot offer a risk-free environment…you agree to reside in the Community with full awareness and acceptance of the inherent risks at the Community.”
During interviews with Residents R2-R11, were asked if they have had any items go missing while living in the facility, seven (7) out of ten (10) stated they have not had any items go missing while living at the facility.
During interviews with Staff S1-S7, were asked how the facility safeguards residents personal belongings, seven (7) out of seven (7) stated they recommend residents to lock their doors to their rooms. Additionally, staff stated it is recommended to residents and responsible parties to inventory residents’ personal property, and to not bring expensive items or large sums of money to the facility.

(5) Continued on LIC9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20240620162835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CITY VIEW LA, LLC
FACILITY NUMBER: 198603220
VISIT DATE: 10/03/2024
NARRATIVE
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During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Business Manager, Vanita Harris, and a copy of this report was provided.















(6)
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6