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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205039
Report Date: 07/13/2024
Date Signed: 07/14/2024 09:56:08 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, 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
06/24/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240624132504
FACILITY NAME:ANGEL'S HAVEN IIFACILITY NUMBER:
198205039
ADMINISTRATOR:OSCAR LECHUGAFACILITY TYPE:
740
ADDRESS:28022 ACANA ROADTELEPHONE:
(310) 544-4594
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 4DATE:
07/13/2024
UNANNOUNCEDTIME BEGAN:
08:21 AM
MET WITH:Vicenta Mendoza TIME COMPLETED:
10:42 AM
ALLEGATION(S):
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Staff neglect led to resident sustaining pressure injury.
Resident sustained unexplained injuries.
Staff inappropriately restrained resident.
Staff did not treat resident with dignity and respect.
Staff did not provide resident with privacy.
Staff did not provide a comfortable temperature for residents.
INVESTIGATION FINDINGS:
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On 07/13/24, Licensing Program Analyst (LPA) Ernand Dabuet made a subsequent unannounced visit to this facility and was greeted by the staff Vicenta Mendoza (S1). LPA explained the purpose for today’s visit is to gather information for the allegations mentioned above and deliver findings.

The investigation consisted of the following: An initial 10-Day visit was conducted on 07/03/24 a subsequent visit on 07/13/24 by LPA DAbuet. (LPA) requested copies of client and staff roster. (R1's) Admission Agreement (dated: 01/05/24), Physicians Report (dated: 10/25/23), Preplacement Appraisal LIC 603 (dated: 01/05/24), Resident Appraisal LIC 603A (dated: 01/26/24) Appraisal/Needs Services Plan LIC625 (dated: 01/26/24), Client Weight Record (dated: 01/01/24 - 06/01/24) and other pertinent documents associated with this complaint. Interview conducted with residents #1-#4 (R1-R11), and Administrator #1 (A1) staff #1-#2 (S1-S3). An iinspection of the facility was conducted.

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

DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024
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 6
Control Number 11-AS-20240624132504
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: ANGEL'S HAVEN II
FACILITY NUMBER: 198205039
VISIT DATE: 07/13/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

ALLEGATION #1: Staff neglect led to resident sustaining pressure injury.


ALLEGATION #2: Resident sustained unexplained injuries.
The details of the complaint alleged due to staff neglect resident #1 (R1) sustained pressure injuries. The complainant observed on 06/23/24 a bruise on the chest and right arm (R1). Several weeks back the complainant also observed a bed sore on (R1’s) buttock area. The complainant reported the staff were unable to explain the reason for the bruises and bed sore when inquired. The complainant was not available to provide further details on this allegation.

Investigation revealed (R1) was admitted to Angel’s Haven II on 01/05/24 in accordance with the Admissions Agreement (dated: 01/05/24). (R1) received hospice care from Divine Hospice Services, Inc., effective 01/07/24.

On 07/03/24, between 09:00 am – 10:15 am, the Department interviewed (4) out of (4) residents #1-#4 who denied having sustained any bruises or pressure injuries while in care. (R1) claimed to have no bruises on the chest and arms nor a bed sore on (R1’s) buttocks area. (R1-R4) are complimentary of staff and the care and assistance they all receive from each of the staff.

On 07/03/24, between 09:30 am – 10:45 am, the Department interviewed (3) out of (3) administrator #1(A1) and staff #1-#2 (S1-S2) claimed this allegation was false. (A1 and S1-S2) stated no residents in care have sustained any bruising or pressure injuries while in care. (A1 and S1-S2) claimed that (R1) is under hospice care with Divine Hospice Services, Inc., and it is under medical professionals with a registered nurse (RN) and licensed vocational nurse (LVN) twice a week. (A1-S1) claimed the facility staff was only responsible for (R1)’s non-medical care since the facility is a non-medical care facility. (A1 and S1-S2) pointed out that although they are not trained medical professionals, the facility staff is capable of caring for and supervising residents. (R1) is not bedridden and can reposition in bed, according to (A1-S1).

On 07/03/24, between 02:28 pm – 02:45 pm, the Department interviewed (5) out of (5) witnesses #1 - #5 (W1-W5) denied residents ever sustained bruises or pressure injuries while in care. (W1) a registered nurse (RN) from Divine Hospices Services confirmed that (R1) has been under hospice care since 01/07/24 and that this accusation is false. (Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20240624132504
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: ANGEL'S HAVEN II
FACILITY NUMBER: 198205039
VISIT DATE: 07/13/2024
NARRATIVE
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(W1) stated if had any type of pressure injuries or bruising (R1). (W1) claimed a wound care specialist would have been required, and a wound care plan would have been established. (W1) commented that (R1) is under-prescribed medications that have side effects that can cause unusual bleeding or bruising.

On 07/03/24, the Department examined (R1) and did not observe any bruises or bed sores. A review of the hospice medication list (dated: 01/05/24) revealed (R1) is prescribed nine (9) medications. Seven (7) out of (9) prescribed medications have side effects that can cause unusual bleeding or bruising in accordance to the National Institute of Health (ref: NIH). Based on the information gathered, there is no evidence to support the allegation mentioned above.

ALLEGATION #3: Staff inappropriately restrained resident.
The complainant alleged resident #1 (R1) was improperly restrained while in care. The complainant reported the facility staff is improperly restraining (R1) in a wheelchair or chair, attaching an alarm cord to (R1’s) clothes so that whenever (R1) moves, the alarm goes off. According to the complainant, the staff has informed (R1) that (R1) is not allowed to leave the chair. The complainant did not provide further details on this matter.

On 07/03/24, between 09:00 am – 10:15 am, the Department interviewed (4) out of (4) residents #1-#4 (R1-R4) indicated they were not restrained by any devices that would prevent their mobility. (R1) claimed not to feel limited in mobility even having a magnet alarm attached to (R1’s) clothing.

On 07/03/24, between 09:30 am – 10:45 am, the Department interviewed (3) out of (3) administrator #1(A1) and staff #1-#2 (S1-S2) claimed this allegation was incorrect. (A1 and S1) communicated the residents are not restrained from mobility. (R1) is a fall risk. The fall plan approved by hospice included a magnet alarm with a cord attached to (R1’s) clothing that will sound off when (R1) is seated and attempts to rise off only while in a recliner and it is not used while in a wheelchair. (A1-S1) reported that there are no vests, ties, or belts attached to this system to restrain (R1’s) mobility. Furthermore, when the monitor system is activated, (R1) is not limited from mobility as it is only used to summon a staff when (R1) stands pulls away to trigger the alarm and is redirected.

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

DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20240624132504
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: ANGEL'S HAVEN II
FACILITY NUMBER: 198205039
VISIT DATE: 07/13/2024
NARRATIVE
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On 07/03/24, between 02:28 pm – 02:45 pm, the Department interviewed (5) out of (5) witnesses #1 - #5 (W1-W5) and claimed no residents are restrained while in care. (W1) a registered nurse (RN) from Divine Hospices Services confirmed that (R1) is a fall risk and part of the fall management is to have a magnet alarm on (R1) as an added assistance for monitoring (R1) to prevent further life-threatening falls.

A review of (R1’s) Physician Report LIC 602A (dated: 10/23/23) and Appraisal/Need Services Plan (dated: 01/20/24) indicated (R1) is an ambulatory, fall risk and requires assistance and supervision. Divine Hospice Services records (dated: 01/05/24) outlined (R1) is a fall risk and a plan is included. Based on the information gathered, there is no evidence to corroborate the allegation mentioned above.

ALLEGATION #4: Staff did not treat resident with dignity and respect.
ALLEGATION #5: Staff did not provide resident with privacy.
It is alleged the facility staff did not treat resident # 1 (R1) with dignity and respect nor provide privacy during visits. The complainant reported the staff are preventing (R1) from receiving phone calls and privacy during visitations. The complainant did not offer further details on these allegations.

On 07/03/24, between 09:00 am – 10:15 am, the Department interviewed (4) out of (4) residents #1-#4 (R1-R4) communicated that the facility treated them with dignity and respect. (R1-R4) expressed the facility staff treated them with care and compassion and had no issues or concerns with privacy during appointment visits.

On 07/03/24, between 09:30 am – 10:45 am, the Department interviewed (3) out of (3) administrator #1(A1) and staff #1-#2 (S1-S2) stated this is untrue. (A1 and S1-S2) reported that all residents are given privacy during appointment visits from family members or health agencies. (A1) stated the residents can have their private visits indoors or outdoors, and incoming calls are not being monitored or refused.

On 07/03/24, between 02:28 pm – 02:45 pm, the Department interviewed (5) out of (5) witnesses #1 - #5 (W1-W5) and claimed to have no issue with how the residents were treated. (W2) power of attorney for (R1) is complimentary of the staff and stated that (R1’s) health has improved since assisted with care and supervision at this facility.
(Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20240624132504
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: ANGEL'S HAVEN II
FACILITY NUMBER: 198205039
VISIT DATE: 07/13/2024
NARRATIVE
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(W2) expressed that staff were respectful of their privacy during visits and observed staff communicate with residents with empathy and kindness. (W1-W5) claimed they have not been denied access to residents with phone calls or visits. Based on the information gathered, there is no evidence to support the allegation mentioned above.

ALLEGATION: #6: Staff did not provide a comfortable temperature for residents.
It is alleged by the complainant that on 06/23/2024, there was no air conditioning in the facility, and the doors and windows were closed. The complainant did not offer additional detailed information on this matter.

The Department conducted a health and safety inspection on 07/03/24 at 9:00 am – 12:30 pm and found the temperature in the facility to be within Title 22 regulations. The facility thermostat read 76.0 degrees F. Portable free-standing fans were available in all the resident’s rooms and a Vagkri portable air conditioner unit was in the living room and dining room area. The room temperature in bedroom #1 is 78.0 degrees F; bedroom #2 is 78.0 degrees F; bedroom #3 is 77.0 degrees F. The kitchen, dining, and living rooms had temperatures of 77.0 - 78.0 degrees F. The Department observed windows and sliding doors, the front door was not closed, and an outdoor breeze was filtered through the rooms.

On 07/03/24, between 09:00 am – 10:15 am, the Department interviewed (4) out of (4) residents #1-#4 (R1-R4) claimed that the facility provided a comfortable temperature for residents in care. (R2 and R4) long-term residents since 2021 have never felt uncomfortable with the temperature in the facility as there are heating and cooling systems equipped in all the rooms.

On 07/03/24, between 09:30 am – 10:45 am, the Department interviewed (3) out of (3) administrator #1(A1) and staff #1-#2 (S1-S2) stated this accusation was false. (A1) described that the home is not equipped with built-in air conditioning and only equipped with heating. (A1 and S1-S2) reported during summer months when the temperature rises, they ensure the fans are operating and there is enough circulation throughout the facility. Moreover, the staff monitors the residents for liquids and body temperature.

On 07/03/24, between 02:28 pm – 02:45 pm, the Department interviewed (5) out of (5) witnesses #1 - #5 (W1-W5) claimed to have no issues with the temperature in the facility. (W1-W5) reported that temperature has always been comfortable during visits at the facility and did not observe any residents neglected in care due to uncomfortable temperature. (Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20240624132504
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: ANGEL'S HAVEN II
FACILITY NUMBER: 198205039
VISIT DATE: 07/13/2024
NARRATIVE
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According to public records, this facility is a single-family home built in 1962 with (3) bedrooms and (2) baths and 1,334 square feet of space. It has heating and no cooling which verified the statement remarked by (A1). Based on the information gathered, there is no evidence to corroborate the allegation mentioned above.

Based on information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Vicenta Mendoza, and copies of the reports were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6