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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204399
Report Date: 10/04/2024
Date Signed: 10/04/2024 03:12:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
09/25/2024 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240925143751
FACILITY NAME:VILLA REDONDO CARE HOMEFACILITY NUMBER:
198204399
ADMINISTRATOR:MARIA BRAVOFACILITY TYPE:
740
ADDRESS:237 REDONDO AVENUETELEPHONE:
(562) 434-9931
CITY:LONG BEACHSTATE: CAZIP CODE:
90803
CAPACITY:80CENSUS: 64DATE:
10/04/2024
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Kyra OlguinTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not prevent resident from causing harm to another resident.
Staff did not report incident.
INVESTIGATION FINDINGS:
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The investigation consisted of the following: On 09/27/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Staff Kyra Olguin and explained the purpose of the visit. The Administrator Maria Bravo joined us later. During today’s investigation, LPA Cloyd reviewed facility records, two resident records, observed lunch, and interviewed residents and staff members.

On 10/04/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA met with Staff Kyra Olguin and explained the purpose of the visit. During today’s investigation, LPA Cloyd interviewed residents, Assistant Administrator, and reviewed facility records.

Continue to LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
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-20240925143751
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA REDONDO CARE HOME
FACILITY NUMBER: 198204399
VISIT DATE: 10/04/2024
NARRATIVE
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Allegation(s):
Staff did not prevent resident from causing harm to another resident.

The investigation revealed the following: Regarding the allegation "Staff did not prevent resident from causing harm to another resident,” it is being alleged that on 02/10/24 8:00 AM and 09/05/24 8:00 AM, Resident #1 (R1) was scratched in the face by Resident #2 (R2). The Report of Suspected Elder Abuse (02/10/24) revealed that the police were contacted to file a report and both residents were advised to stay away from one another. The Unusual Incident Report (09/05/24) revealed that responsible parties were notified, R1 and R2 will be monitored for changes in condition, R1’s behavior would be monitored, and residents will be encouraged to keep their distances. Interview with the Administrator indicated that both residents have been encouraged to use different elevators to avoid being in the same hallway for breakfast. The Administrator also indicated that conversations have been had with both Power of Attorneys regarding the incidents and the facility rules. Four out of five residents indicated staff supervise the area near the dining room halls around breakfast. Four out of six residents indicated that they feel safe at the facility.

Regarding the allegation “Staff did not prevent resident from causing harm to another resident,” based on record review and interviews, 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, as a result, the allegation is Unsubstantiated.

Allegation(s):
Staff did not report incident.



The investigation revealed the following: Regarding the allegation " Staff did not report incident,” it is being alleged that resident-on-resident (Resident #1 and Resident #2) incident was not reported to the Long-Term Care Ombudsman Program. Record review revealed that The Report of Suspected Elder Abuse (02/10/24) was reported to the Police Department, Community Care Licensing, and Ombudsmen. The Unusual Incident Report (09/05/24) was sent to Community Care Licensing and a police report was filed. Interview with the Administrator indicated that the Wellness Director left a voicemail on the general line at the Ombudsmen’s office. Administrator also indicated that the Licensed Vocation Nurse documented and sent the Elder Abuse form and the Wellness Director documented and sent the Unusual Incident Report.

Continue to LIC9099-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240925143751
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA REDONDO CARE HOME
FACILITY NUMBER: 198204399
VISIT DATE: 10/04/2024
NARRATIVE
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Regarding the allegation “Staff did not report incident,” based on record review and interviews, 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, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegations.

An exit interview was conducted and a copy of this report was provided to the Staff Kyra Olguin.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3