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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320199
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:49:08 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
06/27/2023 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:
04/09/2024
UNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:LaToya Johnson, Administrator TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not provide proper medication assistance to resident in care.
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. 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 LaT]oya Johnson, Administrators.
The investigation consisted of the following:
On 04/09/24 LPA interviewed 4 residents. 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.
Unsubstantiated
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 2
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: 04/09/2024
NARRATIVE
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The investigation revealed the following:
Regarding the allegation: "Staff did not provide proper medication assistance to resident in care.". It has been alleged that the above-mentioned facility could not store or administer proper comfort care medications. Interviews revealed that five (5) out of 5 staff and three (3) out of four (4) residents have denied the allegation, while one (1) resident was unable to provide a verbal or visual response.

Record reviews revealed that staff Aurora Ortiz (S3) was properly instructed by a skilled nurse regarding the appropriate administration of comfort care medications for resident one (R1) on 03/01/23 and that there was a stop in morphine administration on 04/11/23. On 05/25/23 R1's registered nurse from Kaiser Hospice (RN), made a visit to R1, upon which S3 was informed by RN to follow order as received. According to Medication Admissions Record (MAR), S3 provided one (1) dose on 05/25/23, 1 dose on 05/27/23, and 4 doses on 05/28/23. On 05/29/23 RN provided a new order for the medication to be administered every six (6) hours, around the clock, and to continue previous order of 1 dose every hour as needed. MAR noted around the clock doses began on 05/29/23.

Based on record reviews and interviews conducted, the preponderance of evidence standard has/has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was conducted with LaToya Johnson, Administrator, and a copy of this report has 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 2