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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320407
Report Date: 02/23/2024
Date Signed: 02/23/2024 12:38:46 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
12/20/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20231220153341
FACILITY NAME:PEPPER TREE ASSISTED LIVING IIIFACILITY NUMBER:
198320407
ADMINISTRATOR:KLEIN, STEPHANIEFACILITY TYPE:
740
ADDRESS:24608 PENNSYLVANIA AVENUETELEPHONE:
(310) 947-2165
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:5CENSUS: 2DATE:
02/23/2024
UNANNOUNCEDTIME BEGAN:
07:59 AM
MET WITH:Marhly SapugayTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee is operating beyond the scope of their license.
Licensee is not ensuring that the facility is propertly secured.
Resident's are left unsupervised while in care.
Uncleared adult (s) working at the facility.
INVESTIGATION FINDINGS:
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On 02/23/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to deliver findings regarding the above allegations. LPA Richard met met with administrator Marhlyn Sapugay. LPA Richard and Adminitrator Flores toured the physical plant.

The investigation consisted of the following:
On 12/22/2023, LPA Richard reviewed and requested, staff and resident's records. LPA requested three residents (R1-R3) residents, and Two (2) staff (S1-S2) files. LPA Richard requested facility documents. Physician report, Needs of service plan, staff and resident roster, employee schedule, first aid certificate, training log. Due to times constrained and resident tested positive for Covid-19 the above allegations need further investigation.
On 02/23/2024, LPA Richard conducted a subsequent complaint to deliver findings regarding the above allegations.
Report Continues, See LIC9099C.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
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 4
Control Number 11-AS-20231220153341
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: PEPPER TREE ASSISTED LIVING III
FACILITY NUMBER: 198320407
VISIT DATE: 02/23/2024
NARRATIVE
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The investigation revealed the following:
Regarding allegation: Licensee is operating beyond the scope of their license.

It is alleged that the licensee is operating beyond the scope of their license. LPA Richard interviewed the administrator about the complaint allegation. The administrator stated that during the pre-licensing on 11/16/23, the application initially was for six ambulatory residents. However, due to insufficient space the capacity was reduced to five (5) residents. The administrator stated that she has never gone beyond three residents since the facility opened, the facility has been losing residents for the last past two months. Now the facility capacity has been reduced by two (2) residents. LPA reviewed the resident roster and interviewed R1-R2. They both state that they only remembered two or three of them living here. R1-R2 stated that now it only the two of us.

Based on information gathered, records reviewed, and interviewed, LPA did not find enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore, the allegation is unsubstantiated.

Regarding the allegation: Licensee is not ensuring that the facility is properly secured.

It is alleged that Licensee is not ensuring that facility is properly secured. LPA Richard toured the facility with the administrator, LPA observed there is an auditory devices to notify staff when someone walks through the backdoor from the room. The administrator stated that the facility is not a locked and there are no alarms. However, the facility has an auditory device on exits through the backdoor.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20231220153341
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: PEPPER TREE ASSISTED LIVING III
FACILITY NUMBER: 198320407
VISIT DATE: 02/23/2024
NARRATIVE
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LPA asked the administrator to test the backdoor auditory device. There was a loud sound when the back door was opened. LPA interviewed staff (S1-S3) the staff stated that the residents don’t go outside without the staff accompanying them. The residents mostly stayed inside the living room area, watching TV and playing games. LPA interviewed residents R1-R2 both stated that it is cold to go outside right now they always asked the staff go outside with them if they want to go out. The residents R1-R2 stated that they feel secured, especially when going downstairs to play with the other residents.

Based on observation, records reviewed, and interviewed, LPA did not find enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore, the allegation is unsubstantiated.

Regarding the allegation: Resident are left unsupervised while in care.

It is alleged that the resident's are left unsupervised while in care. LPA Richard observed open entry to the facility, there was a staff member present, and there was a staff member at the facility while the residents were eating breakfast. LPA interviewed the resident R1-R2 regarding the residents left unsupervised at the facility, and the residents stated that staff were always present at the facility. The residents said they used the pendant to call the staff if they needed help. The residents stated that going downstairs is a plus, and they are never alone. LPA interviewed staff S1-S3 regarding the allegation; the staff stated that the facility always has one staff present upstairs if a resident doesn’t want to come downstairs. Staff stated that no residents were ever left alone upstairs at any given time.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20231220153341
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: PEPPER TREE ASSISTED LIVING III
FACILITY NUMBER: 198320407
VISIT DATE: 02/23/2024
NARRATIVE
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Based on information gathered, records reviewed, and interviews conducted, LPA did not find enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore, the allegation is unsubstantiated.

Regarding the allegation: Uncleared adult (s) working at the facility.

It is alleged that uncleared adult (s) working at the facility, LPA Richard reviewed the personnel file and showed that all the staff S1-S3 and everyone associated with the facility have a background clearance on file. The administrator stated that they do not hire anyone unless their background is cleared. On 02/12/24, Personnel Report Summary (LIS) showed everyone associated with the facility was cleared.

Based on information gathered, record reviewed, and interviews conducted, LPA did not find sufficient evidence to support the allegation. Although the allegation 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 allegation is unsubstantiated.

There were no deficiencies cited. Exit interview conducted a copy of this report was provided to the administrator Marhlyn Sapugay.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4