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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608379
Report Date: 03/22/2024
Date Signed: 03/23/2024 12:26:57 AM

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
07/17/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230717150430
FACILITY NAME:AVENIDA VILLA, INC.FACILITY NUMBER:
197608379
ADMINISTRATOR:PHILLIP ROMEROFACILITY TYPE:
740
ADDRESS:1803 AVENIDA FELICIANOTELEPHONE:
(310) 930-6455
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 6DATE:
03/22/2024
UNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:enaida BunagTIME COMPLETED:
05:34 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner.
Staff did not notify Resident's Representative about resident's change in condition in a timely manner.
Staff did not ensure that resident's grooming needs were met while in care.
INVESTIGATION FINDINGS:
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On 03/22/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility, LPA was greeted by administrator Zenaida Bunag. LPA explained the purpose of today's investigation visit was to gather information and deliver findings for the allegations mentioned above.

The investigation consisted of the following: LPA reviewed the roster of residents and staff. A review of resident #1 (R1's) Phyysician's Report, Appraisal/Needs and Service Plan, Incident Report, Facility Progress Notes, Facility Visitors Logs, Providence Trinity Care Hospice Care Plan, Declaration LIC 855, LA County Sheriff's Police Report, and other pertinent documents associated with this complaint. Interviews with the administrator, staff, residents, and witnesses. A tour of the facility on 07/27/23 and 03/22/24.

(Evaluation Report continues on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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 5
Control Number 11-AS-20230717150430
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: AVENIDA VILLA, INC.
FACILITY NUMBER: 197608379
VISIT DATE: 03/22/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff did not seek medical attention for resident in a timely manner.
Allegation #2: Staff did not notify Resident's Representative about Resident's change in condition in a timely manner.
The details for this complaint alleged that facility staff did not seek medical attention for resident # (R1) in a timely manner nor did not notify (R1’s) representative about (R1’s) change in condition timely. The complainant reported that staff did not adequately check on (R1) before (R1’s) death on 01/22/22 nor did staff seek medical attention for (R1) when staff observed a change in condition. The complainant did not have further additional details on these matters.

Resident #1 (R1) was admitted at Avenida Villa on 09/18/18 after a discharge from Lomita Acute Center. Upon discharge, (R1) was placed on home health services by Torrance Home Health. (R1) was recertified for home health throughout 2018-2022. (R1) had a change of condition that required a higher level of care and family representatives for (R1) were notified and agreed to admit (R1) for hospice with Providence Trinity Care Hospice effective 01/18/22 up to (R1’s) passing on 01/22/22. (R1) was always under the care of medical professionals with home health and hospice nurses and doctors.

On 08/09/23, the Department received a written Declaration LIC 855 (dated: 08/09/23) from administrator #1 (A1). (A1) claimed that (R1) was under professional supervision and care with nurses and doctors while (R1) was at Avenida Villa. (R1’s) family members were always at the facility during home health and hospice visits with nurses discussing (R1’s) condition. (A1) stated when it came to (R1’s) medical needs it was always taken care of by the home health and hospice medical professionals. (A1) claimed the facility staff were only responsible for (R1’s) non-medical care since the facility is a non-medical care facility.

On 03/22/24, between 9:30 am – 1:07 pm, the Department interview (3) out (3) administrator (A1) and staff #1-#2 (S1-S2) all verified that (R1) was being monitored on 01/22/22 hourly by staff before (R1’s) passing. (A1) and (S1) communicated they checked on (R1) at 7:30 am and 8:00 am on 01/22/22. At 8:00 am (S2) checked (R1’s) blood pressure, pulse, and changed (R1’s) diaper, and applied ointment. (R1) was still conscious at that time. (A1-S2) check on (R1) again at 9:00 am and (R1) was non-responsive. (A1) called the hospice nurse and family to inform them that (R1) was non-responsive. (A1) immediately contacted (R1’s) family representatives of (R1’s) change of condition. A hospice medical professional arrived along with the family representatives at 10:00 am on 01/22/22.

(Evaluation Report continues LIC 9099-C)

This report serves as an amendment to clarify finding in line #23. It does not supersedes the complaint investigation findings reflected on report created 03/22/24.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230717150430
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: AVENIDA VILLA, INC.
FACILITY NUMBER: 197608379
VISIT DATE: 03/22/2024
NARRATIVE
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Emergency Medical Services (EMS) was dispatched by family representatives and arrived. Hospice medical professional declared (R1) deceased on 01/22/22 at the facility.

The Department reviewed the Providence Trinity Care Hospice care plan (dated: 01/26/22) and it revealed (R1) was placed on hospice on 01/19/22, (R1) was diagnosed with a terminal illness. Hospice visits were indicated on 01/19/22, 01/20/22, 01/21/22, and 01/22/22.

The Department reviewed the Facility Progress Notes (dated: 10/19/21 through 01/22/22) and it revealed that (R1) was being observed and monitored at least every two hours for repositioning, change of condition, or diaper changes.

On 03/22/24, between 10:45 am – 11:37 am, the Department interviewed (5) out (7) residents #2-#6 (R2-R6) all claimed that staff are responsive and are observant to resident's changes in condition. (R2-R6) reported that when they require assistance, the staff is responsive within minutes when called. As a result of (R1's) passing and (R7's) health condition, it was not possible to interview both residents.



On 03/22/24 between 01:30 pm – 02:30 pm, the Department interviewed (2) out (3) family representatives witness #2-#3 (W2-W3) claimed the facility is well maintained with qualified staff and is managed adequately. (W2-W3) who are very much involved with resident care at this facility with frequent visits and have not witnessed any activity of neglect or lack of care toward residents. Telephone calls made to family representative witness #1 (W1) were not acknowledged, and no comments were obtained.

Based on the evidence gathered interviews conducted, and records reviewed, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations of NEGLECT/LACK OF CARE: “Staff did not seek medical attention for resident in a timely manner” and “Staff did not notify Resident's Representative about resident's change in condition in a timely manner” are found to be UNSUBSTANTIATED.

Allegation #3: Staff did not ensure that resident's grooming needs were met while in care.

It is alleged that staff did not ensure that resident #1 (R1’s) grooming needs were met. The complainant reported that staff did not shave (R1) for at least the week before (R1’s) passing on 01/22/22 and found this to be a concern. The complainant did not have further additional details on these matters.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20230717150430
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: AVENIDA VILLA, INC.
FACILITY NUMBER: 197608379
VISIT DATE: 03/22/2024
NARRATIVE
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On 08/09/23, the Department received a written Declaration LIC 855 (dated: 08/09/23) from administrator #1 (A1). (A1) claimed that (R1) was entitled to (R1’s) personal rights. There were often times when (R1) declined to receive help with hygiene and grooming care assistance from staff. The staff is respectful of (R1’s) rights and has the right to refuse basic services.

On 03/22/24, between 9:30 am – 1:07 pm, the Department interview (3) out (3) administrator (A1) and staff #1-#2 (S1-S2) all confirmed that (R1) was under home health and hospice care and that home aide would come to assist with hygiene and grooming care. The facility staff would step in when (R1) refused hygiene and grooming services from home aide assistants. According to (A1-S1), (S2) had better chances of assisting with hygiene and grooming needs since (R1) preferred (S2) to conduct these services when (R1) was in a receptive condition.

The Department reviewed the Facility Progress Notes (dated: 10/19/21 through 01/22/22) and it revealed (R1) was not neglected in care for hygiene or grooming needs.

On 03/22/24, between 10:45 am – 11: 37am, the Department interviewed (5) out (7) residents #2-#6 (R2-R6) reported that staff were able to provide satisfactory assistance with their hygiene and grooming needs. Neither (R1) nor (R7) could be interviewed due to their passing or medical condition.

On 03/22/24 between 01:30 pm – 02:30 pm, the Department interviewed (2) out (3) family representatives witness #2-#3 (W2- W3) expressed satisfaction with the facility staff's hygiene and grooming practices. A number of telephone calls were made to the family representative witness #1 (W1), but no response was received.

The Department reviewed complaints # 11-AS-20211011095607 and 11-AS-20221114091332 associated with resident #1 (R1’s) allegations of neglect and lack of care were determined unsubstantiated. A review of the County of Los Angeles Sheriff's Department report LMT23198-0104 determined there was no neglect or abuse of an elder in the report.

(Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230717150430
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: AVENIDA VILLA, INC.
FACILITY NUMBER: 197608379
VISIT DATE: 03/22/2024
NARRATIVE
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Based on the evidence gathered interviews conducted, and records reviewed, 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 of NEGLECT/LACK OF CARE: "Staff did not ensure that resident's grooming needs were met while in care" is found to be UNSUBSTANTIATED.

An exit interview conducted with Zenaida Bunag, and a copy of the report was issued.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5