198320051-3-11-2022-11-AS-JHAD-CERNVE-20220525104746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320051
Report Date: 03/11/2022
Date Signed: 03/11/2022 12:50:58 PM

Unsubstantiated

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
11/15/2021 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211115092738

FACILITY NAME:	PEPPER TREE ASSISTED LIVING		FACILITY NUMBER:	198320051
ADMINISTRATOR:	KLEIN, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	2353 251ST STREET		TELEPHONE:	(310) 947-2165
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	6	CENSUS: 5	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Mila Santos, House Manager		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not reposition resident
Staff did not change diapers timely
Staff did not bathe resident
Resident sustained a pressure injury while in care
Staff did not administer medications to resident
Staff did not change residents bedding

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Mila Santos, the facility house manager.

The investigation consisted of following: Interviews and Record reviews. On 11/19/2021, LPA interviewed S#1, R#2, & R#3. On 03/07/2022, LPA interviewed Administrator and S#2. LPA requested and received the following documents: Face sheets, Pre-Appraisals, Physician's Report, Medical Notes, and Hospice notes for R#1.

Based on the LPA's investigation, the investigation revealed the following. For Allegation 1 - Staff did not reposition resident. Interviews with Administrator, S#1, & S#2, stated that Silverado hospice would take care of repositioning for R#1. The staff only assisted when requested by Hospice nurses. They would only help when asked to by hospice nurses.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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-20211115092738

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: PEPPER TREE ASSISTED LIVING	FACILITY NUMBER: 198320051
	VISIT DATE: 03/11/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Hospice nurses were taking care of R#1 24/7, R#1 had continuous care. R#1 always had a around the clock nurse taking care of R#1 and facility staff available when needed. Interviews with R#2 & R#3 stated that they did not need repositioning, but the staff there are great. They help them with all their needs. LPA reviewed hospice notes and facility care plan revealed that the repositioning of R#1 was done by the hospice nurses and staff would help at times, when requested and needed. The interviews conducted and records reviewed did not concur with the above allegation.

Allegation 2 - Staff did not change diapers timely. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice did not need them to change diapers. They would change diapers, but since R#1 had G-tube there was no needed to change the diapers. Staff spoke with Silverado hospice and explained the even though R#1 had a g-tube R#1 still required to have the diaper checked and change if needed. Interviews with R#2 stated R#2 does not need diapers, R#2 goes to the bathroom on her own. R#3 stated the staff only changes R#3 diapers at night in morning R#3 goes to the bathroom on her own. They never leave R#3 in a soiled diaper. LPA Soto reviewed hospice notes they revealed that they were changing R#1 diapers every 3 hrs. when needed. Interviews conducted and records reviewed did not concur with the above allegation.

Allegation 3 - Staff did not bathe resident. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice would take care of bathing R#1. They would give R#1 sponge bath every morning. Facility staff washed R#1 hair to help hospice nurses. Interviews with R#2, stated that R#2 bates themselves. R#3 stated that the staff bathes R#3 3x a week, they are very good about that. LPA Soto reviewed hospice notes they revealed that Silverado hospice was bathing R#1 every morning. Interviews conducted and records reviewed did not concur with the above allegation.

Allegation 4 - Resident sustained a pressure injury while in care. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice noted that R#1 returned from hospital with the pressure injury. Silverado hospice noted it on their assessment the first day R#1 arrived. Interviews with R#2 & R#3, stated that they have never had pressure injuries, so they do not know anything about that. LPA Soto reviewed hospice notes they revealed that Silverado hospice did note on their assessment of R#1, R#1 had the pressure injury when R#1 returned from hospital. Interviews conducted and records reviewed did not concur with the above allegation.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20211115092738

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: PEPPER TREE ASSISTED LIVING	FACILITY NUMBER: 198320051
	VISIT DATE: 03/11/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation 5 - Staff did not administer medications to resident. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice gave R#1 all their medication. Interviews with R#2 & R#3, stated that they always get their medication on time, staff has never forgotten to give them their medication. LPA Soto reviewed hospice notes they revealed that Silverado hospice handled R#1 medication. Facility staff did not administer R#1 medications. Interviews conducted and records reviewed did not concur with the above allegation.

Allegation 6 - Staff did not change residents bedding. Interviews with Administrator, S#1, & S#2 stated that they always change the residents bedding. They replace the bedding 2x a week and when needed due to accidents. Interviews with R#2 & R#3, stated that they always have their bedding changed, at least once a week. Their bedding is always clean. LPA observed R#2 & R#3, bedding they were clean. The interviews and LPA’s observations did not concur with the above allegation.

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 Mila Santos, House Manager, and a hard copy was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3