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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205367
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:12:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
09/12/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220912155048
FACILITY NAME:WESTCHESTER VILLAFACILITY NUMBER:
198205367
ADMINISTRATOR:EVANGELINE AGATEPFACILITY TYPE:
740
ADDRESS:220 W. MANCHESTER BLVD.TELEPHONE:
(310) 673-1093
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY:174CENSUS: 88DATE:
05/05/2023
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Evangeline AgatepTIME COMPLETED:
02:31 PM
ALLEGATION(S):
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Staff failed to properly care for resident resulting in resident requiring hospitalization.
INVESTIGATION FINDINGS:
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 On 05/05/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent visit to the facility and was greeted by administrator staff #1 (S1) Evangeline Agatep. LPA spoke to (S1) prior to entering the facility to conduct a risk assessment. (S1) informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following: LPA Dabuet conducted the 10-day visit on 09/13/22 with operations manager Karla Yumul and licensee Matthew Chinichian. LPA toured the facility Chinichian and requested copies of the following documents: Facility staff and Resident rosters; Admission Agreement, Appraisal/Needs and Services Plan, Physician’s Report, medical records (to include hospital records), Medication Administration Records and Unusual Incident/Injury Report for Resident #1 (R1). A plant inspection of the facility including room #246 for (R1). (Evaluation Report continues on LIC 9099-C)


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
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 7
Control Number 11-AS-20220912155048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
VISIT DATE: 05/05/2023
NARRATIVE
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A separate investigation was conducted by the Department of Social Services, Investigator Olivia Spindola that included a review of hospital medical records, interview with witness, facility staff, and facility residents.

INVESTIGATION REVEALED THE FOLLOWING:
Allegation #1: Staff failed to properly care for resident resulting in resident requiring hospitalization.

The investigation revealed that on 09/10/22 Resident #1 (R1) was taken by witness #1 (W1) to Torrance Memorial Hospital due to poor health condition. A review of the medical records revealed upon admission to the hospital, (R1) was diagnosed with Acute Renal Failure, Acute UTI, Dementia, Anemia, and Hypertension. Interview with (W1) revealed staff #1 (S1) had informed (W1) that (R1) had been refusing to leave (R1’s) room for several days and appeared to be confused for approximately one week. (R1) was confused and associated with episodes of vomiting. An interview with (W1) stated (W1) was surprised when (W1) arrived at the facility on 09/10/22, after receiving a call from (S1) called (W1) instead of dispatching an ambulance for (R1) to receive emergency medical care. According to (W1), (R1) appeared as if (R1) had a stroke, and (R1) had been vomiting all morning. A statement from staff #2 (S2) revealed (S2) notified (S1) that (R1) had been acting confused and did not want to get out of bed for approximately one week. According to (S1), even though (R1) health had been deteriorating for the past several months, during the last week of living at the facility (R1) appeared confused. In a statement from (W1) and (S2), (R1) had fallen weeks before hospital admission. An interview with (R1) stated no water had been consumed for a few days, except for when taking medications at bedtime, and that (R1) had fallen a couple of days before being hospitalized. (R1) remained under care at the hospital until 10/04/22 and was discharged to a skilled nursing facility and did not return to the assisted living facility according to (R1's) recommendation for a higher level of care. A review of (R1's) file revealed facility staff failed to document (R1) decline in condition nor records of previous falls.

Based on interviews, observations, and supporting medical records and law, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION is substantiated.

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

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20220912155048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
VISIT DATE: 05/05/2023
NARRATIVE
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Based on the Department's observation, interviews, records reviewed and analysis, the preponderance of evidence standard has been met, therefore the allegation of “Staff failed to properly care for resident resulting in resident requiring hospitalization” is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

Civil Penalty:
An immediate $500 Civil Penalty assessed.

Enhanced Civil Penalty:
At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20220912155048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
05/06/2023
Section Cited
CCR
87466
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87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses...
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Licensee/Administrator shall read Title 22, Section 87466 “Observation of the Resident” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 05/06/23 by fax 323-981-1781.
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This requirement is not met as evidenced by:

Based on interview and gathered information, (S1) admitted such changes in (R1’s) health condition and failed to seek timely medical attention. The violaiton poses a immediate health and safety risk to residents in care.
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*IMMEDIATE CIVIL PENALTY *
Under Appeal
Type B
05/19/2023
Section Cited
CCR
87211(1)(B)(D)
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87211 Reporting Requirements - (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... (B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident...
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Licensee/Administrator shall read Title 22, Section 87211 “Reporting Requirements” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 05/19/23 by fax 323-981-1781.
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This requirement is not met as evidenced by:

Based on IB report an interview with (R1) POA (W1) and (S2), (R1) had fallen several weeks prior with no SIR sent to CCLD.The violaiton poses a potential health and safety risk to residents in care.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
09/12/2022 and conducted by Evaluator Ernand Dabuet
COMPLAINT CONTROL NUMBER: 11-AS-20220912155048

FACILITY NAME:WESTCHESTER VILLAFACILITY NUMBER:
198205367
ADMINISTRATOR:EVANGELINE AGATEPFACILITY TYPE:
740
ADDRESS:220 W. MANCHESTER BLVD.TELEPHONE:
(310) 673-1093
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY:174CENSUS: 88DATE:
05/05/2023
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Evangeline AgatepTIME COMPLETED:
02:31 PM
ALLEGATION(S):
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Facility failed to ensure a safe and healthful environment for a resident during a hot climate.
Staff left resident in a soiled diaper for extended period.
INVESTIGATION FINDINGS:
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On 05/05/23, Licensing Program Analyst (LPA) Ernand Dabuet initiated a subsequent complaint investigation visit and met with Administrator Evangeline Agatep to investigate and deliver findings for the allegations mentioned above.

The investigation consisted of the following: LPA obtained copies of the roster for residents and staff. Interviews conducted with Resident #1-#8 (R1-R8), staff #1-#3 (S1-S3), and witnesses #1 (W1). A reviewed of (R1's) service records and other pertinent documents associated to the allegations on this complaint. A tour of the facility was performed including (R1's) #246 room.

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

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20220912155048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
VISIT DATE: 05/05/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #2: Facility failed to ensure a safe and healthful environment for a resident during a hot climate.
It is alleged that resident #1 (R1) was in an extremely hot room with no air conditioning and inside a locked room. An interview on 09/13/22 with witness #1 (W1) claimed at 11:15 am on 09/10/22 there were issues with (R1) and was notified by staff #1 (S1). Upon arrival at 12:30 pm-12:45 pm on 09/10/22 and was escorted by that administrator, (R1’s) room door was locked, and the room temperature was very hot inside. (W1) described the sliding door that lead to the balcony as partially open. A fan was provided, and it was not operating. An interview (S1) disputes this allegation. (S1) recalls the door was unlocked, the fan was operating, and the sliding door was completely open for air circulation. (S2) who was present on 09/08/22 with (W1) and (S1) recalls the door was locked and a key was used unlock door, the fan was working, and the sliding door was open. (S2 -S3) added that residents would lock the door themselves for privacy. During the inspection visit on 09/13/22 the Department observed, (R1’s) room was locked and a key was used to open the door. However, it was to remain locked as (R1) was not present at the facility and was at the hospital during the inspection visit. The Department observed at 10:00 am the temperature was 77 degrees F on 09/13/22 with room sliding door was open. The air conditioners were operating in all the common areas. Interviews with residents #2-#8 (R2-R8) had no issues with the temperature during the week of 09/04/22 through 09/10/22 and found their rooms at a comfortable temperature. The Department investigated on 09/06/22 Complaint Control #11-AS-20220902131031 for “Facility failed to provide a comfortable temperature for resident in care” and determined the allegation as unsubstantiated. (R1) was no longer a resident at the facility and was not available for a statement. Based on the gathered information, there is no evidence to support the allegation mentioned above.

Allegation #3: Staff left resident in a soiled diaper for an extended period.
It is alleged that resident #1 (R1) remained in a soiled diaper for an extended period. The complainant had no further details on the matter. An interview on 09/13/22 with witness #1 (W1) had observed (R1) in an unclean smelly diapers on 06/09/22 when (W1) had to take (R1) to a medical appointment on the same day. (W1) claimed this was the only time (W1) ever noticed (R1) in this condition.
(Evaluation Report continues on LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20220912155048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
VISIT DATE: 05/05/2023
NARRATIVE
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An interview with primary caregivers for (R1) staff #2-#3 (S2-S3) both stated that (R1) is independent until the week when (R1’s) health started to decline, and ended up in the hospital. (R1) can change out of clothes, completed daily hygiene, and can change in and out of pull-up diapers. (S2-S3) stated (R1) was monitored after each meal and was assisted with incontinence briefs. (S2-S3) claimed (R1) was never left in malodorous soiled diapers for an extended time. A review of (R1’s) Physician’s Report LIC 602A dated 03/29/21 indicated (R1) "is able to care for own toileting needs” and “able to dress/groom self." Appraisal/Needs and service Plan LIC 625 Physical/Health dated 04/30/21: “Staff will encourage and assist (R1) to participate in personal hygiene task”. An interview with (R2-R8) classified as "supportive care residents" were complimentary of the staff and expressed the staff are responsive and do not neglect their basic needs. (R1) was no longer a resident at the facility and was not available for a statement. Based on the gathered information, there is no evidence to corroborate the above claim.

Based on information gathered, an inspection of the facility, observation, analysis of (R1's) service records, and interviews conducted, the Department found no evidence to support the allegations mentioned in this complaint.

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 Evangeline Agatep, and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7