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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603504
Report Date: 05/02/2025
Date Signed: 05/02/2025 11:54:28 AM

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
01/22/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250122154956
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: 76DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Andrea Lopez, Business Office ManagerTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff did not notify authorized representative of incident.
Staff are not repositioning resident every 2 hours.
Resident received an unexplained injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit was explained to Business Office Manager Andrea Lopez.

The investigation consisted of: On 1/31/2025, a physical plant tour of the interior common areas, record review, and staff interviews with (S1- S7) was completed. Resident (R1) passed away on 1/29/2025 and was not interviewed. Resident (R1's) files documents [Face Sheet, Hospice Care Plan, Charting Notes, Skin Integrity Monitoring Form, LIC 500 Personnel Report, and resident roster were obtained. During today's visit, LPA toured the physical plant, with special focus on bedridden resident rooms. Residents (R2- R6) were observed and interviewed.


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

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
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-20250122154956
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: 05/02/2025
NARRATIVE
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Allegation: Staff did not notify authorized representative of incident. It is alleged that on January 20, 2025, resident (R1's) authorized representative observed a bruise under the resident's right eye and questioned staff about the incident. A total of seven staff were interviewed. Based on interviews conducted, the findings indicate that on January 17, 2025 at approximately 7:30 AM, morning shift caregiver staff (S3) observed the bruise. Caregiver immediately reported the observation to AM shift med-techs, whom typically contact the resident's physician, hospice, and responsible party. However, in this case the two (2) AM med-techs on duty on January 17, 2025 failed to report the incident to family and forgot to communicate the incident with the next shift med-tech. Additionally, the bruise incident was not documented on the facility electronic software system or charting notes. Per Charting Notes records, staff did not document the bruise that was observed on January 17, 2025, but a Skin Integrity Monitoring Form was completed. Staff acknowledged the incident was not reported to R1's responsible party and documentation/communication protocols were not followed. Therefore, there is sufficient evidence to corroborate the allegation.

Allegation: Staff are not repositioning resident every 2 hours. It was reported that hospice resident (R1) required repositioning every 2 hours due to a sacral pressure injury, but despite regular hospice wound care the pressure injury was getting worse. Seven (7) staff were interviewed. Caregiver staff stated they checked on the resident every 2 hours, and as the resident's health declined staff were checking on the resident at least every hour. Staff stated sometimes R1 refused to be repositioned every 2 hours because the resident preferred to lay in bed in a flat position due to pain when rotated to the side. Staff acknowledged that sometimes the NOC shift caregiver staff did not log in routine checks. It is unknown if they performed rotations on the resident. One of the NOC shift staff (S8) in question was terminated on January 24, 2025 for misconduct and suspicions of improper handling of cognitively impaired residents during incontinence changes. Bedridden residents were interviewed. One (1) resident stated staff are not repositioning every 2 hours, especially during night time. Charting notes [1/1/25 - 1/29/25], records indicate that the majority of the time R1 was routinely being checked every 2 hours. However, on several dates staff checked the resident past the required repositioning time. In addition, many of the documented checks did not specify whether the resident was repositioned every 2 hours. There is sufficient evidence to corroborate the allegation.


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

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250122154956
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: 05/02/2025
NARRATIVE
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Allegation: Resident received an unexplained injury. On January 17, 2025, AM shift caregiver staff observed a bruise under resident (R1's) right eye. The injury was documented on a Skin Integrity Monitoring Form and med-tech staff were notified. None of the residents interviewed reported staff rough handling incidents that have caused bruising. All seven (7) staff interviewed confirmed that resident (R1) had a bruise under the right eye. Staff interviews revealed that former NOC shift staff (S8) stated that when the resident was being turned the resident's hand hit their own face. Staff stated that R1 was experiencing agitation behaviors during repositioning assistance, and may have unintentionally hit themselves. The majority of staff interviewed do not believe the bruise was intentionally caused by malicious intent, but confirmed the resident sustained an unexplained bruise. Picture evidence was obtained.

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

Exit interview was conducted with Business Office Manager Andrea Lopez. 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: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20250122154956
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: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/03/2025
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities...... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Executive Director shall conduct staff training on incontinence care, repositioning, care and supervision, and adherence to facility Plan of Operation protocol procedures.

Submit a written plan by tomorrow, and proof of staff training by Tue. May 6, 2025.
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Based on interviews and records review, the findings indicate that on several dates in the month of Jan. 2025 caregiver staff did not reposition hospice resident (R1) every 2 hours as required. R1 had a pressure injury. This posed an immediate health and safety risk to the resident.
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Request Denied
Type B
05/09/2025
Section Cited
CCR
87211(a)(1)
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Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below..... This requirement was not met evidenced by:

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Executive Director shall provide in-service training regarding reporting procedures/requirements. Please submit a written plan and proof that all caregiver and med-tech staff were trained.
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Based on record review and interviews conducted staff did not notify R1's responsible party of the bruise staff observed on 1/17/25 under R1's right eye. Responsible party observed the bruise on 1/20/25. Note: Staff did not submit an incident report to CCL as required. This posed a potential health and safety 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: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250122154956
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: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
05/09/2025
Section Cited
CCR
87411(d)(3)
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Personnel Requirements - General. All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following....(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.


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Executive Director shall ensure that all staff receive repositioning and procedure training of bedridden residents.

Submit plan of correction and proof of staff training.
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Based on interviews and record review, the findings indicate noc shift (S8) repositioned bedridden resident (R1), and the following day (1/17/25) staff observed bruising under R1's eye. This posed a potential health and safety risk to resident 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: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5