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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603317
Report Date: 03/20/2023
Date Signed: 04/03/2023 02:53:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230315130009
FACILITY NAME:VINE RESIDENCEFACILITY NUMBER:
198603317
ADMINISTRATOR:LOPEZ, LORRAINEFACILITY TYPE:
740
ADDRESS:1405 E. VINE AVETELEPHONE:
(626) 890-7634
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
03/20/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Lorraine Lopez TIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff restrained resident in care
INVESTIGATION FINDINGS:
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***This report serves as an amendment and supersedes the original complaint investigation report created on 03/15/2023. The purpose of this amended Licensing report is to add additional information from the original complaint. The information does not change the finding of the complaint and remains Substantiated***

Licensing Program Analyst (LPA) Christine Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 (S1)/Caregiver Sandra Portillo who allowed entry into the facility and was later met by Administrator Lorraine Lopez who assisted with the visit.


(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
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 28-AS-20230315130009
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VINE RESIDENCE
FACILITY NUMBER: 198603317
VISIT DATE: 03/20/2023
NARRATIVE
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 The investigation consisted of the following: LPA interviewed two (2) staff (S1 and S2), administrator and six (6) residents (R2-R7), R1’s family member and R1 via telephone and obtained R1 documents including the face sheet, physician report, resident appraisal, functional capacity assessment, hospice documents and medication lists.

The investigation revealed of the following: Allegation "Staff restrained resident in care. "LPA interviewed residents and reported staff did restrain resident with a cloth belt. LPA interviewed staff and admitted they did put a belt on R1's recliner to prevent R1 to get up and fell as R1 has a history of fall. The administrator also reported they were using the postural support on R1 but it's not tight at all. They were using the postural support because they were trying to prevent resident to get up and fell as R1 likes to get up all the times. Administrator also indicated R1’s family member was acknowledged the postural support for R1 and did see the picture of the postural support and it was not considered as a restraint on R1. During the record review, LPA observed the postural support (gait belt) that R1 used which was not prescribed by R1’s physician.

Based on the interviews conducted by staff and residents and record reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099D

Exit interview held/copy of report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230315130009
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VINE RESIDENCE
FACILITY NUMBER: 198603317
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2023
Section Cited
CCR
87608(a)(5)
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87608 Postural Supports (a)a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
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5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. The requirement is not met as evidenced by: LPA's interviews and record review, R1 was put on a belt while he was sitting on a recliner to prevent R1 to get up and fell which posed a potential 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230315130009

FACILITY NAME:VINE RESIDENCEFACILITY NUMBER:
198603317
ADMINISTRATOR:LOPEZ, LORRAINEFACILITY TYPE:
740
ADDRESS:1405 E. VINE AVETELEPHONE:
(626) 890-7634
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
03/20/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Lorraine Lopez TIME COMPLETED:
11:35 AM
ALLEGATION(S):
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9
Staff does not let resident go to the bathroom
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation and to establish the validity of the complaint. LPA met with Staff #1 (S1)/Caregiver Sandro Portillo who allowed entry into the facility and was later met by Administrator Lorraine Lopez who assisted with the visit.

The investigation consisted of the following: LPA interviewed two (2) staff (S1 and S2), administrator and six (6) residents (R2-R7) and obtained R1 documents including the face sheet, physician report, resident appraisal, functional capacity assessment, hospice documents and medication lists.

The investigation revealed of the following: Allegation "Staff does not let resident go to the bathroom" LPA interviewed residents and all denied the allegation. Residents reported that staff would let them to go to the bathroom and they have no issues with that.
(See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230315130009
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VINE RESIDENCE
FACILITY NUMBER: 198603317
VISIT DATE: 03/20/2023
NARRATIVE
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LPA interviewed staff and all denied the allegation too. Staff reported all residents need assistance with toileting except one resident. They would never reject resident to go to the bathroom. They would assist resident with changing diaper every two hours or as needed. During the record review, R1 is incontinence and requires assistance with toileting needs. R1 was not able to go to the bathroom alone.

Based on interviews conducted and recorded view, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit Interview Conducted and A copy of the report was provided to Administrator Lorraine Lopez.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5