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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320199
Report Date: 03/18/2024
Date Signed: 04/09/2024 01:47:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO 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
06/27/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230627141017
FACILITY NAME:KEEN HOME LONG BEACHFACILITY NUMBER:
198320199
ADMINISTRATOR:ADRIEN HERBASFACILITY TYPE:
740
ADDRESS:6441 BIXBY HILL RDTELEPHONE:
(562) 438-5336
CITY:LONG BEACHSTATE: CAZIP CODE:
90803
CAPACITY:6CENSUS: 4DATE:
03/18/2024
UNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Aurora Ortiz, Direct Care Staff LeadTIME COMPLETED:
05:37 PM
ALLEGATION(S):
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Staff tried to change resident's hospice care plan without proper authorization
INVESTIGATION FINDINGS:
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On 04/09/2024 Licensing program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the above mentioned facility to deliver this amended document. LPA was met by Aurora Ortiz, Direct Care Staff Lead and the purpose of the visit was explained. LPA was later met by Adrien Herbas and Latoya Johnson, Administrators.
The investigation consisted of the following:
On 03/18/24 LPA requested training records for all staff who were present during resident one's presence and resident one's hospice care plan. LPA also interviewed two (2) staff who were present at the facility.
On 06/28/23 LPA conducted an unannounced complaint visit to the above mentioned facility. LPA was met by Aurora Ortiz, Team Lead, and later by Adrien Herbas, Administrator, who were both informed that this visit was conducted to investigate the above complaint allegation and LPA requested resident roster, staff roster, hospice care plans, physician reports, pre-placement appraisals, appraisals, identification and emergency contacts and other service documents which related to rental fees and back pay. A plant inspection was conducted and above mentioned records were reviewed. Report continues, see LIC9099C.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
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-20230627141017
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: KEEN HOME LONG BEACH
FACILITY NUMBER: 198320199
VISIT DATE: 03/18/2024
NARRATIVE
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The investigation revealed the following:

Regarding the allegation "Staff tried to change resident's hospice care plan without proper authorization". It has been alleged that one hospice provider was requested not to return to the above-mentioned facility.

Interviews revealed that two (2) out of 2 staff members have agreed that one worker was requested not to return to the facility.

LPA's record reviews revealed that the facility does not contain a written hospice care plan for resident one. According to the terms and conditions of the hospice waiver, approved on 09/17/2021, section 6 is stated as follows: "Prior to the initiation of hospice services in the facility, the licensee will ensure a written hospice care plan is developed for each terminally ill resident or prospective resident, that specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility by that resident’s hospice agency, and agreed to by both the licensee and the resident or prospective resident or the resident’s or prospective resident’s Health Care Surrogate Decision Maker.". The facility was unable to provide a copy of any incident report(s), LIC624, of the incident; which has been mandated by the reporting requirements of the department, California Code of Regulations 87633(g).

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached deficiency. Please see LIC9099D.

An exit interview was held with Latoya Johnson, Administrator, and a copy of this report and appeal rights have been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230627141017
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: KEEN HOME LONG BEACH
FACILITY NUMBER: 198320199
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/22/2024
Section Cited
CCR
87633(g)
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(g) In addition to...section 87211, Reporting Requirements, the licensee shall submit a report to the department when...hospice services are interrupted or discontinued for any reason other than the death of the resident, including refusal of hospice care or discharge from hospice. The licensee shall also report
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The administrator and LPA have agreed that any incident resulting in any deviation, or incident, of a resident's hospice care plan will be reported to the department of social services via fax number at 424.544.1016.
Licensee will let LPA know about reception of this deficiency and will forward an update to
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any deviation from the resident’s hospice care plan, or other incident, which threatens the health and safety of any resident.
This has not been met as evidenced by: a requested change of a social worker, which had not been reported to the department.
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their admission agreement which includes, but not limited to, section 6 of the hospice waiver approval letter, approved on 09/17/2021 via email to mario.leon@dss.ca.gov
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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: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
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