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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608562
Report Date: 04/14/2021
Date Signed: 04/14/2021 11:16:49 AM

Substantiated


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 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
11/18/2019 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20191118130624
FACILITY NAME:SENIORS' HAVEN LLCFACILITY NUMBER:
197608562
ADMINISTRATOR:JORGE ADLE MENDOZAFACILITY TYPE:
740
ADDRESS:1831 NORTH KENWOOD STREETTELEPHONE:
(818) 843-3572
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:6CENSUS: 0DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jorge Mendoza (Administrator)TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff failed to dispense resident's medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long delivered complaint findings for the allegation list above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today's complaint finding delivery was conducted telephonically with Jorge Mendoza (Administrator).

During a site visit on 11/27/19, LPA interviewed Staff #1 in the dining area at 10:20 am and toured the facility at 10:50 am with Staff #1.

In regards to the allegation: Facility staff failed to dispense resident's medication as prescribed. A review of the medication log indicate that Staff did not assist Resident #1 and #2 with the self-administration of medications during November of 2019. Also, Witness #1 witnessed the resident had not been receiving their medication.

Continue to LIC9099D....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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 28-AS-20191118130624
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SENIORS' HAVEN LLC
FACILITY NUMBER: 197608562
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2021
Section Cited
HSC
1569.69(a)(2)
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In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in
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Licensee shall provide additional medication administration assistance training to staff and will provide proof of training to the Department by the POC date.
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subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Staff did not assist Resident #1 and #2 with the self-administration of medications during November of 2019.
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Note: There are currently no residents or staff in the facility. Licensee shall provide a signed statement which indicate that newly hired staff will receive the proper training based the Health & Safety Code 1569.69.
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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: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20191118130624
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SENIORS' HAVEN LLC
FACILITY NUMBER: 197608562
VISIT DATE: 04/14/2021
NARRATIVE
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Based on LPA's record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Per Health & Safety Code, the deficiency observed is documented on LIC809D. Failure to correct the deficiencies may result in civil penalties.

A telephonic exit interview was conducted with Jorge Mendoza and a hard copy and appeal rights was provided via email for signature.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3