<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603504
Report Date: 10/25/2024
Date Signed: 10/25/2024 04:16:56 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
08/05/2024 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240805162120
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: 87DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Diana Bautista, Administrator TIME COMPLETED:
04:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide resident’s authorized representative a copy of the admission agreement in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegation.The purpose of the visit was discussed with Administrator Diana Bautista.

The investigation consisted of: LPA completed a physical tour of the common areas and resident (R1's) room. Interviews with family (F2) and Administrator was conducted. Record review of incontinence care Narrative Charting logs [July 2024- to present] and August 2024- to present Medication Administration Records (MARs), and Admission Agreement was completed. Copies of the MARs and Narrative Charting logs, and rosters were 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: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 28-AS-20240805162120
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: 10/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff did not provide resident’s authorized representative a copy of the admission agreement in a timely manner. The complaint alleges that resident (R1's) responsible party never received a copy of the signed Admission Agreement after multiple requests addressed to Administration staff. Based on record review, the findings indicate that resident (R1) moved in to the facility on November 17, 2023. The Admission Agreement was provided until August 5, 2024. LPA obtained a copy of the Admission Agreement, and it was determined the Admission Agreement signed and provided to R1's responsible party is the former licensee's Admission Agreement. On 12/7/2023, the facility was issued a citation for issuing Admission Agreements that were in place when the facility was owned by a previous licensee. Administrator acknowledged they did not provide a copy, and the copy provided is not the correct form. Therefore, there is sufficient evidence to corroborate the allegation. A civil penalty is being assessed.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are 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: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240805162120
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: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
87507(e)
1
2
3
4
5
6
7
Admission Agreements. The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification.
1
2
3
4
5
6
7
Administrator shall submit a copy of the plan of operation addressing Admission agreements, a written plan, and proof that R1's authorized representative were issued the copy of the admission agreement.
*This is a repeat violation. Civil penalties are being assessed.

8
9
10
11
12
13
14
This requirement was not met evidenced by: Based on record review of email correspondence, R1's family never received a copy of the admission agreement after it was signed, until multiple requests later. On 8/5/24, the copy was provided, but R1 was admitted on 11/17/23.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3