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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204938
Report Date: 08/12/2021
Date Signed: 08/12/2021 11:26:17 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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2021 and conducted by Evaluator Don Senaha
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210318152046
FACILITY NAME:BRENT WOOD VILLAFACILITY NUMBER:
198204938
ADMINISTRATOR:KENNETH PITTSFACILITY TYPE:
740
ADDRESS:17004 ATKINSON AVENUETELEPHONE:
(310) 538-2284
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: DATE:
08/12/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:TIME COMPLETED:
09:41 AM
ALLEGATION(S):
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Facility staff restrained resident
INVESTIGATION FINDINGS:
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On 08/12/2021, Licensing Program Analyst (LPA) Don Senaha initiated a subsequent investigation visit to delivery findings.

On 03/24/2021 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via facetime with Administrator Bien Cadungog.

The investigation consisted of the following: interviews conducted with Administrator Bien Cadungog, residents (R1-R6) and staff (S1-S3). Residents (R1-R2, R6) refused to interview. LPA requested and obtained pertinent records for review.

A plant inspection of the facility was conducted on 03/24/2021 and 08/12/2021.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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 11-AS-20210318152046
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: BRENT WOOD VILLA
FACILITY NUMBER: 198204938
VISIT DATE: 08/12/2021
NARRATIVE
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Allegation: Facility staff restrained resident

On 03/24/21 at 12:32pm, LPA entered resident (R1) room via facetime during plant inspection. LPA observed resident (R1) bed with a short bed rail on the left side of the bed towards the front of the bed. Bed had a recliner remote control hanging and red cloth ties which were tied to the short bed rail near the front of the bed of resident (R1).

On 03/24/2021 at 1:37pm, LPA had Administrator go back to resident (R1) room with staff (S2) to explain the red cloth ties tied on to the bed. Staff (S2) stated he used the cloth ties to keep resident (R1) from falling out of bed and staff (S2) used it to tie it to the chair in the back so if resident (R1) did fall it would make a noise and call to staff (S2) attention.

LPA reviewed pertinent records of resident (R1) and did not find any request or reference to resident (R1) needing to be restrained.

Based on LPA’s observations, interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20210318152046
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: BRENT WOOD VILLA
FACILITY NUMBER: 198204938
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2021
Section Cited
CCR
87608(a)(5)
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87608 Postural Supports (a) Based on the individual’s preadmission appraisal, the facility… (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident’s hands or feet.

This requirement is not met as evidenced by:
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The Licensee agreed to review California Code of Regulations Title 22 Section, Division 6, Chapter 8, Article 11. Health-Related Services and Conditions. Licensee read the Title 22 regulations 87608(a)(5) and signed letter in LPA presence that he understands this regulation.
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Based on observation, record reviews and interviews, the licensee did not follow under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident’s hands or feet, which poses an immediate health and safety risk to persons in care.
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The Licensee immediately removed the cloth ties from the R1 bedside.


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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: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3