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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191600749
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:55:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20241203111041
FACILITY NAME:VILLA SORRENTOFACILITY NUMBER:
191600749
ADMINISTRATOR:CARLA CHANFACILITY TYPE:
740
ADDRESS:23450 MADISONTELEPHONE:
(310) 539-6826
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:145CENSUS: 103DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure client's room is free of clutter
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/10/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Administrative Assistant, Trish Morales and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 12/10/24, LPA Shirley spoke to facility Executive Director, Carla Chan and reviewed facility records. LPA requested copies of staff and resident rosters, copies of ALW program documents, Cleaning schedule, Special Incident Reports involving injuries from clutter in the rooms and special incident reports involving R-1. LPA also interviewed staff 1 thru staff 10(S1 thru S10) and residents 1 thru resident 10(R-1 thru R-10). LPA received copies of residents, Admissions Agreement, Emergency Contacts, Physician’s report, and preplacement appraisal.

The investigation revealed the following:
Con't on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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 11-AS-20241203111041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 12/10/2024
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 does not ensure client’s room is free of clutter.

On 12/10/24, upon arrival to this facility, LPA Shirley toured facility for a health and safety check and also inspected R-1’s room and observed that there are numerous items in which R-1 stated that she is keeping for sentimental reasons. There are concerns that these items could easily eventually become a safety hazard. LPA observed that there are clear paths to the doors, windows, bathroom and kitchenette areas. LPA Shirley reviewed R-1’s Individual’s Service Plan and learned that she is a fall risk and upon review of requested Special Incident Reports noted that R-1 has not had any falls since her admission date of 3/5/24. During interviews and a review of the House Keeping Cleaning Room Assignments, LPA learned that the resident’s rooms are cleaned on a daily basis and are deep cleaned once a week per S-2. The removal of items collected in R-1’s room is a path to achieving a room free of clutter is a journey that R-1 does not have to take alone. Per S-1, staff offers to clean the items and assist with the organization of the items, and that the cleanup process doesn’t just deal with the clutter but the emotional state of the resident while also ensuring that the resident’s personal rights are not violated.

LPA Shirley spoke with and interviewed staff 1 thru staff 10 (S-1 thru S-10). LPA ask, does staff ensure resident’s rooms are free of clutter? Of those interviewed, 10 out of 10 answered, yes. LPA Shirley interviewed residents 1 thru resident 10 (R-1 thru R-10). LPA ask, does staff ensure residents rooms are free of clutter. Of those interviewed, 9 out of 10 answered yes, and 1 resident did not know.

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20241203111041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 12/10/2024
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
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. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff does not ensure clients room is free of clutter” therefore the allegation is unsubstantiated.

No deficiencies issued during this visit.



An exit interview was conducted with Administrative Assistant, Trish Morales and a copy of this report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3