197800100-8-16-2024-11-AS-RORN-D8DLEG-20240822084131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197800100
Report Date: 08/16/2024
Date Signed: 08/16/2024 10:13:41 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
08/12/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240812150918

FACILITY NAME:	CARSON GUEST HOME		FACILITY NUMBER:	197800100
ADMINISTRATOR:	RESURRECCION, CORAZON		FACILITY TYPE:	740
ADDRESS:	22418 CATSKILL AVENUE		TELEPHONE:	(310) 830-2518
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 5	DATE:	08/16/2024
		UNANNOUNCED	TIME BEGAN:	08:11 AM
MET WITH:	Cora Resurreccion		TIME COMPLETED:	10:32 AM

ALLEGATION(S):

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Staff are not providing adequate activities to resident in care.

INVESTIGATION FINDINGS:

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On 08/16/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility. LPA was greeted by Administrator Cora Resurrection. LPA explained the purpose of this visit was to interview the remaining residents and deliver findings for the allegation mentioned above.

The investigation consisted of the following: A copy of the Register of Facility Residents LIC 9020, Facility Personnel Roster, Service records for resident #1 (R1) included: Physicians Report LIC 602A, Identification and Emergency Information LIC 601, Admission Agreement, Preplacement Appraisal Information LIC 603, Medication Administration Record, Vital Signs Log, Facility's Plan of Operation, and Activity's Schedule. An interview with the Administrator, residents #1-#5 (R1-R5), and witnesses #1-#5 (W1-W5). An inspection was conducted of the facility.

(Evaluation Report continues LIC 9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

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-20240812150918

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: CARSON GUEST HOME	FACILITY NUMBER: 197800100
	VISIT DATE: 08/16/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff are not providing adequate activities to resident in care.

The details of the complaint alleged the facility staff are not providing suitable activities to resident # 1 (R1). The information provided indicated (R1) goes to bed early at 05:30 pm and watches television with limited access to television programming channels.

Investigation revealed resident #1 (R1) was admitted at Carson Guest Home on 07/04/24 according to Identification and Emergency Information (dated: 07/01/24). Physician’s Report LIC 602A (dated: 07/03/24) is non-ambulatory and unable to self-care and requires assistance with the activities of daily living (ADLs). Preplacement Appraisal Information LIC 603 (dated: 07/04/24) identified that (R1) enjoyed puzzles, being outside, and watching TV (Family Feud, BET, and Westerns).

On 08/15/24 and 08/16/24 between 09:00am – 02:59 pm, the Department interviewed (4) out of (5) residents #1-#4 (R1-R4) who expressed having no concerns or issues with the daily activities. (R1-R4) claimed the facility offers satisfactory activities daily to keep each resident interested in an active lifestyle. (R1-R4) stated that it is important for them to have the freedom to participate in activities like leisure time, physical exercises, and socialization according to their preferences. (R1) described the ability to have leisure time with family visits, telephone calls, and socializing with other residents. (R1) stated that (R1) is not limited to television programming and can watch favorite shows like BET and Family Feud. (R1) claimed that no staff mandates (R1) to go to bed early; it is (R1’s) choosing to sleep early on certain nights. (R1) stated bedtime is usually 08:30 pm or 9:00 pm is a normal time. (R1) indicated that (R1) is still adapting to life in a private home environment, but (R1) likes the care and supervision offered 24 hours a day. (R5) who was present at the facility was interviewed and unable to hold a conversation as a result of (R5's) health condition.

On 08/15/24 between 01:15 pm – 01:45pm, the Department interviewed (1) out of (1) administrator #1 (A1) who stated that the facility offers plentiful activities for residents in care. (A1) stated is what is important is to match the social factor specifically to each resident interest. The facility program activities included: leisure time, physical exercises, and socialization. The residents are provided entertainment, occupational therapy, and outdoor activities suited to each need. The facility provides transportation to appointments, shopping, and planned trips. (A1) stated has the choice of what daily activities (R1) wants to participate in daily. (R1) often will participate in leisure time watching (R1’s) favorite programs or socializing with residents and visitors. (Evaluation Report continues LIC 9099)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240812150918

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: CARSON GUEST HOME	FACILITY NUMBER: 197800100
	VISIT DATE: 08/16/2024

NARRATIVE

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(A1) due to (R1’s) health condition and ambulatory status is limited in physical outdoor activities. (R1's) vitals are monitored daily and it is recommended by (R1's) medical physician to maintain a healthy blood pressure rate to sleep earlier and longer to reduce the risk of high blood pressure.

On 08/15/24 and 08/16/24 between 08:00 am – 04:30 pm, the Department interviewed family representatives (5) out of (5) witnesses #1-#5 (W1-W5) who articulated to have no concerns with activities offered by the facility. (W1-W5) are completely satisfied with the care and supervision provided by staff. (W1) power attorney to (R1) is complimentary of staff and appreciative of their services provided 24 hours daily. (W1) reported to be involved with (R1) in at least two visits a week and has observed (R1) engaging in activities. Furthermore, (W1) has observed three (3) out of the five (5) residents participating in physical outdoor activities during (W1’s) visits.

As a result of the Department reviewing (R1) Physician Report LIC 602A (dated: 07/01/24), Preplacement Appraisal Information LIC 623 (dated: 07/04/24); Medication Administration Record (dated: 08/01/24-08/31/24), Admissions Agreement LIC604A (dated: 0704/24) confirmed (R1) is limited to physical activities. Residents and administrators' statements were verified through observation of the facility's activities calendar and review of its Plan of Operation. During the investigation, the Department observed individual television in each resident rooms, activity room and living room.

Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. 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 Cora Resurreccion, and a hard copy was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

LIC9099 (FAS) - (06/04)

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