197608379-6-19-2023-11-AS-JHAD-CU9REE-20230731125725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608379
Report Date: 06/19/2023
Date Signed: 06/19/2023 01:19:55 PM

Unsubstantiated

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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/14/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221114091332

FACILITY NAME:	AVENIDA VILLA, INC.		FACILITY NUMBER:	197608379
ADMINISTRATOR:	PHILLIP ROMERO		FACILITY TYPE:	740
ADDRESS:	1803 AVENIDA FELICIANO		TELEPHONE:	(310) 930-6455
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 6	DATE:	06/19/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Honey Jean, Care giver		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Questionable Death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Honey Jean, Care giver.

The investigation consisted of following: Interviews and Record reviews. LPA conducted interviews with Administrator, S#2, & S#3. R#1 - R#6. LPA toured rooms #2 - #5, living room, dining room, and kitchen. LPA requested and received the following documents: Resident Roster, Staff Schedule, Face sheet, Physician's Report, Mars (December and January), Pre-Appraisal, Death report dated 1/22/22, Hospice file, and Death certificate, resident entire file, medical records from Providence LCOM Torrance Oncology, Hospice, and home health. On 05/05/23, LPA interviewed W#1 via telephone.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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 11-AS-20221114091332

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AVENIDA VILLA, INC.	FACILITY NUMBER: 197608379
	VISIT DATE: 06/19/2023

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following.

Allegation – Questionable Death. Interview with S#1 -S#2, communicated that they checked on R#1 at 7:30am and 8am. S#1 went to check on R#1 at 7:30am, S#1 was talking to R#1, R#1 was only blinking at S#1, so S#1 knows R#1 was alive. S#1 left R#1 to go check on the rest of the resident’s, S#1 retuned to feed R#1 yogurt, does not recall what time it was when she returned to feed R#1. R#1 did not respond to S#1, so S#1 called administrator to advise them that R#1 was not responding. S#2 checked on R#1 around 8am, S#2 checked R#1’s blood pressure, pulse, and change R#1’s diaper and applied ointment. R#1 was still alive at that time. S#3 arrived at the facility around 9am and went to check on R#1 and R#1 was non-responsive. S#3 called hospice nurse and family to informed them that R#1 was non-responsive. Hospice nurse and family arrived around 10am. The nurse and family went to check on R#1 and family called 911. Paramedics arrived later, not sure of the exact time. The hospice nurse declared R#1 deceased. LPA reviewed the hospice records. R#1 was put into hospice on 01/19/22, R#1 was diagnosed with a terminal illness. R#1 was not expected to live more than 6 months. R#1 was on hospice for 3 days when R#1 passed away on 01/22/23, from R#1 terminal illness. There were no notes from nurse giving facility specific instructions on who should be called first, second or third in case of R#1 showing signs of distress or passing. The facility followed the procedures when residents are in hospice care. They called hospice first then the family. Interview conducted with W#1, communicated that the hospice nurse did not pronounce R#1 dead, the paramedics pronounced R#1 dead. They don’t recall there being or noticing any rigomortus. LPA reviewed the official Death Certificate, R#1 passed away of coronary artery disease and malignant Melanoma of face. Interviews conducted and records reviewed did not concur with the above allegation.

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

An exit interview was conducted with Honey Jean, Care giver, Care giver, and a hard copy of report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC9099 (FAS) - (06/04)

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