198603247-12-9-2024-11-AS-EMAZ-DCZTVP-20250117140413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603247
Report Date: 12/09/2024
Date Signed: 12/09/2024 03:09:54 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, 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
12/03/2024 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 11-AS-20241203104040

FACILITY NAME:	EVERLASTING HOME CARE		FACILITY NUMBER:	198603247
ADMINISTRATOR:	BULLER, KATHRINA		FACILITY TYPE:	740
ADDRESS:	5413 BROCKWOOD STREET		TELEPHONE:	(562) 421-4855
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 5	DATE:	12/09/2024
		UNANNOUNCED	TIME BEGAN:	10:19 AM
MET WITH:	Buller Kathrina		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.

INVESTIGATION FINDINGS:

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On 12/09/24, the department made an unannounced visit to the facility and was greeted by Staff #1 (S1: Maria Miclat). The department explained the purpose of today’s visit is to conduct a complaint investigation about the above-mentioned allegation. The department later was joined by the Administrator Buller Kathrina.

The investigation consisted of the following: The department toured the residential care facility for the elderly (RCFE) and requested copies of the following pertinent documents: (1) A copy of the residents’ roster; (2) A copy of the staff roster; (3) Physicians’ Report for residents; (4) Resident Hospitalization Records; (5) Appraisal/Needs and Services Plans, thirty days’ notice, SIRs, and the Medication Administration Record (MAR) and Admission Agreement for R1.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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 3

Control Number 11-AS-20241203104040

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: EVERLASTING HOME CARE	FACILITY NUMBER: 198603247
	VISIT DATE: 12/09/2024

NARRATIVE

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Continued LIC9099-C

Allegation: The resident sustained unexplained injuries while in care.

Regarding the allegation resident sustained unexplained injuries while in care. It is alleged that the resident was admitted to Kaiser Permanente Medical Center for pneumonia and was observed to have various discolorations of unknown etiology (Mark) on the body. The department interviewed the Administrator #1 (A1) who stated that on 10/30/24, the Power of Attorney (POA), moved the resident #1 (R1) out of the facility and did not let A1 know where R1 would move. On 12/09/24, the department called and spoke to the (POA) over the phone who stated that POA remove R1 out of the facility due to medical necessity and personal reasons. The POA also stated that on 10/30/24, R1 did not have any discoloration or bruises on the body. The staff was very kind and took good care of R1 while residing at Everlasting Home Care. The hospitalization happened on 11/28/24, while R1 was at the new facility, The Villa. When the nurse observed R1, had pneumonia and called the paramedic who transported R1 to Kaiser Permanente Medical center and on the same day R1 was admitted. The department interviewed two residents (R2-R3) 2 out of 2 stated that they enjoyed living at the facility. The department interviewed two staff (S1-S2) 2 out of 2 stated that they do not restrain residents. The department interviewed the Independent Care Management Witness #1 (W1) who stated that W1 visits R1 twice a month at the facility and did not observe any discoloration or bruises on R1.

Continued LIC9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20241203104040

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: EVERLASTING HOME CARE	FACILITY NUMBER: 198603247
	VISIT DATE: 12/09/2024

NARRATIVE

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Continued LIC9099-C

According to W1, W1 stated that R1 is a very outspoken and would have let W1 know if any abuse happened. W1 also stated that R1 was on blood thinner that may have caused some discolorations to the body. The department records reviewed, dated 10/2024, revealed the resident left the facility a month before being admitted to Kaiser Permanente Medical Center. The department could not interview resident #4, #5, #6 due their cognitive ability. The department could not interview R1 because R1 was not available.

Based on interviews, and record reviews, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or not occur, therefore the allegation is unsubstantiated.

No deficiencies cited. Interview conducted. A copy of this report was provided to the Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3