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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603504
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:47:29 PM

Substantiated


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 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
09/17/2024 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240917111252
FACILITY NAME:LA POSADAFACILITY NUMBER:
198603504
ADMINISTRATOR:DIANA BAUTISTAFACILITY TYPE:
740
ADDRESS:8120 PAINTER AVETELEPHONE:
(562) 945-2651
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:114CENSUS: 85DATE:
09/20/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Diana Bautista, Administrator TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff are not administering medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Wellness Director. Administrator Diana Bautista arrived later.

The investigation consisted of: A physical plant tour of the interior common areas and interviews with residents (R1-R8), and staff (S1-S7) was completed. Resident (R1- R4) files documents, ten (10) Medication Administration Records (MARs), LIC 500 Personnel Report, and resident roster were reviewed and obtained.

*Narrative continues next page.

Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
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 28-AS-20240917111252
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 09/20/2024
NARRATIVE
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Allegation: Staff are not administering medications as prescribed. It is alleged that medication technicians were not refilling medications in a timely manner, pills were being popped but not given to residents, or the pills were not popped at all during the months of May 2024- June 2024. Information obtained alleges that there were at least 10 residents that were not receiving medications as directed by their physicians. Staff interviews revealed that the facility has been experiencing issues with medication technicians during the last 4- 6 months, because med-tech's were not fulfilling their job responsibilities i.e., documenting on the electronic Medication Administration Record (MAR) that the medications were dispensed, or calling for refills with advance notice. Staff stated medications were being administered but there were MAR errors, and lack of documentation on the MAR to prove staff dispensed the medications. A total of 8 residents were interviewed, none reported knowledge of inappropriate dispensing of medications. However, per record review of Medication Administration Records (MAR) of 10 residents, the findings indicate that multiple residents went days without medication administration by med-tech staff. The lack of documentation was observed in all shifts. There is sufficient evidence to corroborate the allegation.


Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D.

Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.


NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240917111252
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LA POSADA
FACILITY NUMBER: 198603504
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care Services. If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
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Administrator agrees to:
1. Submit proof of staff training.
2. Submit a written plan that addresses centrally stored record keeping/inventory protocols, refill procedures, and facility auditing of medications.
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Based on record review, med-tech staff did not dispense medications to at least 10 residents as directed by Physician; records indicate some residents went 2-5 days without medications, which poses an immediate health, safety or personal rights risk to persons 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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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 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
09/17/2024 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240917111252

FACILITY NAME:LA POSADAFACILITY NUMBER:
198603504
ADMINISTRATOR:DIANA BAUTISTAFACILITY TYPE:
740
ADDRESS:8120 PAINTER AVETELEPHONE:
(562) 945-2651
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:114CENSUS: 85DATE:
09/20/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Diana Bautista, Administrator TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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9
Lack of supervision resulted in residents assaulting other residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Wellness Director. Administrator Diana Bautista arrived later.

The investigation consisted of: A physical plant tour of the interior common areas/stairways and interviews with residents (R1-R8), and staff (S1-S7) was completed. Resident (R1- R4) files documents, ten (10) Medication Administration Records (MARs), LIC 500 Personnel Report, and resident roster were reviewed and obtained.

*Narrative continues next page.

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240917111252
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 09/20/2024
NARRATIVE
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Allegation: Lack of supervision resulted in residents assaulting other residents in care. It is alleged that the facility is failing to ensure the health and safety of residents because residents have been sexually assaulted by resident(s). According to information obtained, management staff have knowledge that there is a known registered sexual offender residing at the facility and were made aware of incidents of sexual inappropriateness by resident (R1) towards resident (R2), and possibly towards resident (R3). Additionally, another resident (R4) allegedly verbally assaults residents with sexual comments and conducts themselves in an inappropriate manner towards staff. It was reported that R1 was observed entering the room of a cognitively impaired, non-ambulatory resident. A total of seven (7) staff were interviewed, of which none reported knowledge of suspected sexual assaults towards residents by R1 or R4. Staff stated they have not observed R1 & R4 act inappropriately with other residents. However, all staff stated that R4, has cognitive impairment and frequently says sexual comments to female staff, but stated none of the residents have reported sexual inappropriateness or assault. A total of 8 residents were interviewed, of which all denied the allegation. Residents (R1 & R2) denied the allegation. There is insufficient evidence to corroborate 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 did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted and a copy of this report was discussed and provided to facility Administrator Diana Bautista.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5