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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607689
Report Date: 11/21/2024
Date Signed: 11/26/2024 09:54:58 AM

Substantiated


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
11/14/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241114101530
FACILITY NAME:AMERICARE ASSISTED LIVING OF ROLLING HILLSFACILITY NUMBER:
197607689
ADMINISTRATOR:EDNA DIMALANTAFACILITY TYPE:
740
ADDRESS:4826 ROCKBLUFF DR.TELEPHONE:
(310) 422-5364
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY:6CENSUS: 5DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Leia Joaquin, LicenseeTIME COMPLETED:
02:01 PM
ALLEGATION(S):
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Staff are limiting residents use of the facility bathroom
INVESTIGATION FINDINGS:
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This is an amendment of the investigation report dated on 11/21/2024 the purpose of this amendment is to update the details of the allegation and the deficiency cited. On 09/21/24 The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted an initial complaint visit at the above-mentioned facility. CCLD staff was met by Leia Joaquin, Licensee (S4) and the purpose of the visit was explained.
The investigation consisted of the following:
CCLD staff requested facility documents, which include the following: staff and resident rosters, facility personnel report, facility personnel initial and ongoing training(s), Admission agreement(s), and appriaisal/needs and services plan of resident(s). CCLD staff conducted a tour of the facility with staff one, Adalberto "Bert" Batongbakal (S1). CCLD staff interviewed one (1) resident and four (4) staff.
The investigation revealed the following:
Regarding the allegation "Staff are limiting residents use of the facility bathroom.", it has been alleged that staff installed a latch at the top the restroom door.
REPORT CONTINUES, SEE LIC9099C.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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-20241114101530
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: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689
VISIT DATE: 11/21/2024
NARRATIVE
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During CCLD staff's tour, CCLD staff observed three (3) latches installed on the upper left-hand corner of the doors in room numbers #5, #3 and bathroom #1, which are inaccessible to residents with wandering behaviors. CCLD staff also observed latches on the front and rear entrance and exit passageways from the facility to the outdoors.
Record reviews revealed the following: Four (4) out of five (5) residents are marked as "Non-Ambulatory". Interviews revealed the following: Four (4) out of five (5) residents were not able to provide interviews due to their medical condition. One (1) out of five (5) residents have denied the allegation has taken place. Three (3) out of four (4) staff have denied the allegation has taken place, while one (1) staff is unfamiliar with the facility. S1 indicated two (2) out of five (5) residents have been diagnosed with Dementia and one (1) out of five (5) residents has memory issues. Three (3) out of four (4) staff indicated that one (1) out of five (5) residents have wandering behaviors.
Based on CCLD staff's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited, please see attached LIC-9099D.

One (1) deficiency has been cited, Please see LIC9099D.

During today's visit, an exit interview was held with Leia Joaquin, Licensee, and a plan of corrections were developed. A copy of the deficiency cited, appeal rights, and this report have been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20241114101530
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: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2024
Section Cited
CCR
87307(d)(6)
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87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This has not been met as evidenced by:
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The Licensee had the door latches in rooms 3, 5 and bathroom 1 removed during the investigation.
The Licensee has agreed that the faciility will conduct an in-service training regarding title 22 regulation 87307(d)(6) - Personal Accommodations and Services
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Based on observation and interviews the licensee failed to keep the indoor passageways free from obstruction. CCLD & S1 observed door latches intstalled on rooms 3, 5 and bathroom 1, which poses an immediate risk to the safety and personal rights risk to all residents in care.
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Licensee will submit POC, via email Mario.Leon@DSS.CA.GOV, to CCLD staff on or prior to POC due date.
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
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