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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320366
Report Date: 08/30/2023
Date Signed: 08/30/2023 02:18:22 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
08/23/2023 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20230823115449
FACILITY NAME:FAMILY FIRST BOARD & CAREFACILITY NUMBER:
198320366
ADMINISTRATOR:FAMISAN, ROSEMARIEFACILITY TYPE:
740
ADDRESS:14532 HALLDALE AVETELEPHONE:
(310) 910-6142
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:6CENSUS: DATE:
08/30/2023
UNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:RoseMarie FamisonTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff did not maintain complete file of resident's records
Staff were not trained to care for hospice resident
INVESTIGATION FINDINGS:
1
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On 8/30/23 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived at 8:54am and spoke to Administrator Rosemarie Famison and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following: On 8/30/23 LPA reviewed and requested copies of the following records: Staff files, Resident files, Staff and Resident rosters, Training documents. 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.

The investigation revealed the following:


Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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 2
Control Number 11-AS-20230823115449
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: 08/30/2023
NARRATIVE
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Allegation : Staff did not maintain complete file of resident’s records
On 8/30/23 from 9:15am to 10am LPA Shirley reviewed facility files. During file review, LPA reviewed Facility files for Residents 1 – Resident 6 (R1-R6) and observed: Admission Agreements, Identification and Emergency Info, Physician’s Report/TB Test/Ambulatory Status, Medical consents, Preplacement/Resident Appraisals, Cash Resources, Personal Rights, and Medication Records. All required documentation was present in file.

Based on information gathered, the department did not find sufficient evidence to support allegations “Staff did not maintain complete file of resident’s records.

Allegation : staff were not trained to care for hospice residents
On 8/30/23 at 9:15am LPA reviewed all training records of staff. During file review, LPA found that all Staff completed the following trainings: What to do in Case of an Emergency/911, Bed Positioning for Stroke, and the following Hospice Trainings: What is Hospice/Responsibilities of Hospice versus Facility Staff,(60 mins), How to Preserve skin Integrity, (30 mins), Incontinence care, Repositioning and transferring techniques, (30 mins), Choking, (30 mins), Fortitude Hospice, (30 mins), Oxygen Education, Foley Catheter Education, (60 mins).

Base on information gathered, the department did not find sufficient evidence to support allegations, “Staff were not trained to care for hospice residents.

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: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2