198603580-1-25-2024-28-AS-RORN-D27QSG-20240206112531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603580
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:44:50 PM

Unsubstantiated

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
04/07/2023 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230407155557

FACILITY NAME:	BEVERLY HILLS SENIOR CARE		FACILITY NUMBER:	198603580
ADMINISTRATOR:	DUFRENNE, PATRIA M.		FACILITY TYPE:	740
ADDRESS:	1015 S. ORANGE GROVE AVE		TELEPHONE:	(323) 933-8271
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY:	45	CENSUS: 44	DATE:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Patria Dufrenne		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained a pressure injury while in care
Staff do not monitor resident for change of condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced subsequent complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Licensee Patria Dufrenne and explained the reason for the visit.

The investigation consisted of: During the initial visit conducted on 04/13/23, LPA Gonzalez conducted interviews with Administrator Patria Dufrenne, S1 and R1-5. LPA reviewed R1-5 files. LPA collected copies of Staff/ Resident Rosters and copies of pertinent documents related to complaint allegations. LPA also conducted a tour of the facility inside and out including facility medication room, dining rooms located on the 1st and 2nd floors, and inspection of the following resident rooms: 103, 104, 105, 106, and 108. On 11/28/23, LPA interviewed Administrator Dana Ordonez, and S2-4. LPA reviewed R1's facility file and

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230407155557

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: BEVERLY HILLS SENIOR CARE	FACILITY NUMBER: 198603580
	VISIT DATE: 01/25/2024

NARRATIVE

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collected copies of various documents pertinent to the investigation. LPA conducted a tour of the facility including lobby, dining room, common areas on both 1st and 2nd floor, laundry room and a random selection of resident rooms. LPA collected copies of Staff and Resident Rosters. LPA also conducted a phone interview with R1's home health agency and requested copies of home health care documentation. On 11/29/23, 11/30/23 and 12/6/23, LPA followed up with home health agency to follow up on request for documents. On 12/06/23, LPA received home health care documentation for R1. On 01/23/24, LPA reviewed home health care documents. On 01/25/23, LPA collected copies of Staff and Resident rosters.

Investigation revealed the following: Regarding allegation, Resident sustained a pressure injury while in care, it is alleged that facility staff did not reposition R1, which resulted in the resident sustaining a Stage 2 pressure wound in their sacrum. Per review of home health care documents, LPA observed that R1 did have a Stage 2 pressure wound that was observed by home health staff on 04/07/23. Home health staff was providing wound care for the the Stage 2 pressure wound along with other care and the wound was reported to be healed on 04/26/23. On 04/07/23, Home health staff provided facility staff with instructions regarding care, repositioning and incontinence care. Interviews conducted with facility staff revealed that they were following instructions given to them by the home health nurse. Facility staff stated that they were repositioning R1 every 2 hours as instructed by the home health nurse. Per interview with R1, they stated that they did not have any complaints regarding the facility staff and/ or the care received from facility staff. Based on interviews conducted with staff, R1 and LPAs record review there was not enough supportive evidence to corroborate the reported allegation.

Investigation revealed the following: Regarding allegation, Staff do not monitor resident for change of condition, it is alleged that the facility is understaffed and R1 who is immobile and requires assistance with repositioning was not reposited by facility staff which resulted in R1 sustaining a Stage 2 pressure wound. Per review of home health care documents, LPA observed that R1 is bed bound and was receiving care from Home health including wound care for the Stage 2 pressure wound that they developed and was observed by a home health nurse on 04/07/23. LPA review of records revealed that home health staff provided facility staff with instructions regarding care, repositioning and incontinence care. The wound was reported to be healed on 04/26/23 and R1 continued to receive treatment from home health for other needed care. Interviews conducted with facility staff revealed that they followed instructions given to them by the home health nurse. Facility staff stated that R1 was repositioned every 2 hours as instructed by the home

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230407155557

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: BEVERLY HILLS SENIOR CARE	FACILITY NUMBER: 198603580
	VISIT DATE: 01/25/2024

NARRATIVE

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health nurse. Administrator and staff stated that there is enough staff on schedule to meet the needs of the residents at all times and there is proper coverage when a staff calls out ill. Interviews conducted with 5 out of 5 residents revealed that there are enough staff on schedule and they do not have any concerns about the care they receive and are satisfied with all the services that they are receiving at the facility. LPA reviewed Facility Personnel Reports (LIC500) for 04/2023, 11/2023 and 01/2024 which revealed that the facility is properly staffed to oversee and provide care for the residents in placement. During the visits conducted on 04/13/23, 11/28/23 and 01/25/24, LPA observed that there were enough staff on schedule. Based on statements gathered from interviews conducted with staff, residents and LPA review of documents, there was not enough supportive evidence to corroborate the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Licensee Patria Dufrenne.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

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