198320366-7-28-2023-11-AS-SCIS-CV7MGT-20230830093625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320366
Report Date: 07/28/2023
Date Signed: 07/28/2023 03:43:54 PM

Unsubstantiated

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
07/21/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20230721151022

FACILITY NAME:	FAMILY FIRST BOARD & CARE		FACILITY NUMBER:	198320366
ADMINISTRATOR:	FAMISAN, ROSEMARIE		FACILITY TYPE:	740
ADDRESS:	14532 HALLDALE AVE		TELEPHONE:	(310) 910-6142
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	6	CENSUS: 5	DATE:	07/28/2023
		UNANNOUNCED	TIME BEGAN:	08:24 AM
MET WITH:	Rosemarie Famisan		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff did not address resident’s change in condition

INVESTIGATION FINDINGS:

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On 7/28/23 Licensing Program Analyst (LPA) Felisa Shirley and Licensing Program Manager (LPM) Stephanie Cifuentes, conducted an unannounced complaint visit to the address listed above. LPA and LPM arrived at 8:20 and spoke to Administrator Rosemarie Famison and the purpose of the visit was discussed. LPA and LPM were granted access to the facility.

The investigation consisted of the following: On 7/28/23 LPA and LPM reviewed and requested copies of the following records: Staff files, Staff and Resident rosters, Case Management Progress Notes, Family First Sign in Sheet. LPA also requested and received the following for resident 1 (R1): Admission Agreement, ID and Emergency information, Physician’s Report, Preplacement Appraisal Information, Appraisal/Needs and Services Plan, Medication Administration Records, Hospice Notification, Incident Reports and Death Report.

con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230721151022

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: FAMILY FIRST BOARD & CARE	FACILITY NUMBER: 198320366
	VISIT DATE: 07/28/2023

NARRATIVE

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The investigation revealed the following:

Allegation: Staff did not address resident’s change in condition
On 7/28/2023 at 9am LPA Shirley reviewed facility files. During file review, LPA found that Resident 1 (R1) was admitted to Fortitude Hospice Inc. on 5/16/2023. LPA S Per R1’s hospice folder, facility can send resident to the hospital if needed. LPA Shirley reviewed facility sign in sheet and noted that on 6/4/23 at 2:28pm and 8:30pm there are sign ins from Fortitude Hospice Inc to visit R1.

It is alleged that R1’s condition changed, and facility staff did not appropriately address the change. On 7/28/2023 From 9am to 1pm LPA Shirley interviewed Staff 1-Staff 2 (S1 - S2), Resident 1-Resident 3(R1-R3) and Witness 1-Witness 3 (W1-W3) and learned the following. On June 4, 2023, S1 noted that R1 was having difficulties breathing and her oxygen levels were low, so the facility contacted hospice around 12:30pm. Fortitude Hospice recommended a treatment and stated they would send one of their staff to assess R1. Facility staff completed treatment given to them by hospice and at 2:20pm hospice staff arrived and R1 was stabilized. Early evening, R1’s condition changed again and S1 called hospice agency at 7:19pm, where she and the hospice staff conducted a facetime call regarding residents’ condition. Per W2, R1’s family contacted at this time and Fortitude Hospice recommended continuing care treatment for R1 instead of hospitalization. Family agreed and W3 arrived at facility at 8:30pm for continuing care treatment. R1 passed at 10:43pm.

Based on information gathered, the department did not find sufficient evidence to support allegations " Staff did not address resident’s change in condition.”

An exit interview was conducted and a copy of the LIC 9099 was provided to Administrator Rosemarie Famison.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

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