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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601570
Report Date: 11/02/2024
Date Signed: 11/02/2024 02:03:11 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
01/25/2022 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220125095503
FACILITY NAME:SENIOR LIVING LIFESTYLE- PALOS VERDESFACILITY NUMBER:
198601570
ADMINISTRATOR:ROBERT SMITHFACILITY TYPE:
740
ADDRESS:3832 PALOS VERDES DRIVE NORTHTELEPHONE:
(424) 241-2539
CITY:PALOS VERDES ESTATESSTATE: CAZIP CODE:
90274
CAPACITY:6CENSUS: 4DATE:
11/02/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Robert Smith/LicenseeTIME COMPLETED:
02:02 PM
ALLEGATION(S):
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Staff did not supervise residents resulting in multiple falls and injuries.
Facility did not seek timely medical attention for resident.
Staff are not meeting residents care needs.
INVESTIGATION FINDINGS:
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On 11/2/24 The Department conducted a subsequent complaint visit to render findings of the allegations listed above. The Department met with Robert Smith/Licensee and the purpose of today’s visit was explained. The Complaint was assigned to Community Care Licensing (CCLD) staff on 01/13/23.

The investigation consisted of the following: On 01/26/2022, The Department initiated an unannounced complaint visit investigation and requested records which included physicians report, needs and service plan/appraisal, ID/face sheet, medication administration records, facility resident roster and facility staff roster. The Department interviewed staff (S1-S2) and residents (R1-R2). A plant inspection of the facility was conducted. On 01/27/2022, Community Care Licensing (CCLD) staff continued this complaint investigation and requested resident records.

Evaluation Report continues LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
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 9
Control Number 11-AS-20220125095503
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: SENIOR LIVING LIFESTYLE- PALOS VERDES
FACILITY NUMBER: 198601570
VISIT DATE: 11/02/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation #2: Staff did not supervise residents resulting in multiple falls and injuries.


Regarding the allegation “Staff did not supervise residents resulting in multiple falls and injuries.” It is being alleged that resident was admitted to Torrance Memorial Hospital, on 12/4/21, for a fall that result in a left hip fracture and a left femur fracture. This investigation revealed resident #1 (R1) was admitted to Senior Living Lifestyle – Palos Verdes on 07/24/21. An interview was conducted with Licensee/Robert Smith who stated R#1’s first fall occurred approximately (1) week after R#1’s admission. The department found this fall resulted in serious injuries to the head, hip, and ribs. The Licensee stated that during R#1’s admission to the facility, R#1 was assessed and deemed a “fall risk”. The Licensee stated that after the fall in August of 2021, the facility failed to employ a fall risk plan. The department found on 12/01/21, R#1 fell again at the facility and the fall resulted in a hip and femur fracture. The Licensee stated after the second fall occurred preventative measures were put in place for R#1 when R#1 returned to the facility from skilled nursing in January of 2022. The department conducted and interview with R#1 and R#1 did not recall the falls that occurred while residing in the facility. Based on the departments review of medical records, supporting documentation, and interviews conducted; the department found the facility failed to provide R#1 the appropriate level of care and supervision and this resulted in R#1 sustaining injures due to falls.

Allegation #3: Facility did not seek timely medical attention for resident.
This complaint alleges that the facility did not seek timely medical attention for Resident R1 after R1 fell and sustained serious injuries on 12/1/21.

On 12/01/21, Resident (R#1) fell at the facility, and this resulted in a left hip and femur fracture. The department conducted an interview with Licensee/Robert Smith, who stated he contacted 911 following R#1’s fall; however, the department was unable to find records of this call.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 11-AS-20220125095503
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: SENIOR LIVING LIFESTYLE- PALOS VERDES
FACILITY NUMBER: 198601570
VISIT DATE: 11/02/2024
NARRATIVE
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The department found the Licensee did contact R#1’s Home Healthcare agency on 12/1/21 to conduct an evaluation of R#1 after the fall. On 12/1/21, the Home Health agency conducted the evaluation and found no signs of injury. The Licensee states he also contacted R#1’s family member on 12/2/21 to report the fall. The family member requested Home Health perform an x-ray. The family member visited the facility on 12/4/21 to transport R#1 to the hospital due to Home Health not having the equipment to perform an x-ray on R#1. The department found R#1 fell on 12/1/21 and did not receive medical attention until 12/4/21; therefore, R#1 did not receive timely medical attention for injuries sustained. Additionally, The Licensee did not arrange for R#1’s medical needs to be met or provide transportation.

Allegation #4: Staff are not meeting residents care needs.
It is alleged that staff are not meeting residents care needs, resulting in resident #1 (R1) sustaining injuries. The department found that Resident #1 (R1) was admitted to the hospital 8/5/21 after a un-witnessed fall.

On 01/27/21, the Licensee Richard Smith stated to department that R1 could independently transfer to and from bed and did not need assistance. The Department reviewed R1’s Physician’s report LIC 602A (dated 07/11/21) and Functional Capability Assessment form (dated 07/11/21) which indicated that R1 could not engage in self-care. R1 needs assistance with walking i.e. walker/wheelchair and needs help repositioning in bed from side to side as well as help with personal hygiene tasks. On 12/01/21, when the resident tried to transfer from one bed to another bed, it resulted in a fall. As a result of the fall, R1 sustained a broken left hip and a fractured femur. Licensee Richard Smith did not contact emergency personnel, nor did he transport R1 to the hospital instead he called the resident’s home health agency. According to the home health agency, they did not find any visible injuries; however, on 12/04/21, a family member transported R1 to Torrance Memorial Hospital where R1 was diagnosed with left hip fracture as well as a left femur fracture. Subsequently, the facility did not have a preventative measures plan in place to keep R1 safe, considering this was the second fall that occurred at the facility.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 11-AS-20220125095503
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: SENIOR LIVING LIFESTYLE- PALOS VERDES
FACILITY NUMBER: 198601570
VISIT DATE: 11/02/2024
NARRATIVE
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During this investigation, LPA found sufficient evidence to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).

-An immediate civil penalty of $500 is warranted accordance with California Health and Safety Code. See LIC421IM.

An exit interview was conducted, and a copy of the Complaint Report was given to Robert Smith/Licensee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 11-AS-20220125095503
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: SENIOR LIVING LIFESTYLE- PALOS VERDES
FACILITY NUMBER: 198601570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2024
Section Cited
CCR
87466
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87466 Observation of the Resident.
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When…any.

This requirement was not met as evidenced by:
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The administrator shall read Title 22, section entitled, “Observation of the Resident” and send a plan of correction to LPA Antonine Richard via email to Antonine.Richard@dss.ca.gov.

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Based on interview and record reviews, the licensee failed to provide R1 with more assistance and supervision following discharge from the hospital on 08/07/20021 due to being a high fall risk. R1 continued to experience multiple falls that resulted to a left hip fracture on 12/05/2021, which poses an immediate health and safety risk to persons in care.
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Type A
11/04/2024
Section Cited
CCR
87411(d)
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87411 Personnel Requirements – General (d) All personnel shall be given on-the-job training or have related experience in the job assigned to them. This… following, as … evidenced by safe and effective job performance: (5) Knowledge necessary to recognize early signs of illness and the need for professional help. This requirement was not met as evidenced by:
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The administrator shall read Title 22, section entitled, “Personnel Requirements – General” and send a plan of correction to LPA Antonine Richard via email to Antonine.Richard@dss.ca.gov.
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Based on interview and record reviews, the licensee failed to ensure that staff recognize early signs of the need for professional help, R1 continued to experience multiple falls that resulted to a left hip fracture on 12/05/2021, which poses an immediate health and safety risk to persons in care.
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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: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 11-AS-20220125095503
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: SENIOR LIVING LIFESTYLE- PALOS VERDES
FACILITY NUMBER: 198601570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2024
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.
This requirement was not met as evidenced by:
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The administrator shall read Title 22, section entitled, “ Incidental Medical and Dental Care ” and send a plan of correction to LPA Antonine Richard via email to Antonine.Richard@dss.ca.gov.
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Based on interview and record reviews, the licensee failed to arrange for R#1’s medical needs to be met or provide transportation. , which poses an immediate health and safety risk to persons in care.
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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: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 9
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
01/25/2022 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20220125095503

FACILITY NAME:SENIOR LIVING LIFESTYLE- PALOS VERDESFACILITY NUMBER:
198601570
ADMINISTRATOR:ROBERT SMITHFACILITY TYPE:
740
ADDRESS:3832 PALOS VERDES DRIVE NORTHTELEPHONE:
(424) 241-2539
CITY:PALOS VERDES ESTATESSTATE: CAZIP CODE:
90274
CAPACITY:6CENSUS: 4DATE:
11/02/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Robert Smith/LicenseeTIME COMPLETED:
02:02 PM
ALLEGATION(S):
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Resident (R1) sustained pressure injury while in care.
Facility are not providing residents with food of good quality.
Staff are mismanaging resident’s medication.
INVESTIGATION FINDINGS:
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On 11/2/24, The Department conducted a subsequent complaint visit to render findings of the allegations listed above. The Department met with Robert Smith/Licensee and the purpose of today’s visit was explained. The Complaint was assigned to the Department on 01/13/23.

The investigation consisted of the following: On 01/26/2022, the Department initiated an unannounced complaint visit investigation and requested records which included physicians report, needs and service plan/appraisal, ID/face sheet, medication administration records, facility resident roster and facility staff roster, and R1 medical records (dated: 12/4/21). interviewed staff (S1-S2) and residents (R1-R2). A plant inspection of the facility was conducted. On 01/27/2022, Community Care Licensing (CCLD) staff continued this complaint investigation and requested resident records.

Evaluation Report continues LIC 9099A-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 11-AS-20220125095503
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: SENIOR LIVING LIFESTYLE- PALOS VERDES
FACILITY NUMBER: 198601570
VISIT DATE: 11/02/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation#1: Resident (R1) sustained pressure injury while in care.


This complaint alleges that R1 developed a stage 2 pressure injury after an injury that occurred on 12/4/21. The department interviewed the licensee Richard Smith (S1). The Licensee indicated that the resident #1 (R1) was admitted to Senior Living Lifestyle- Palos Verdes on 07/24/21. R1’s Physician Report (LIC602A) dated 07/11/21 revealed that (R1) is ambulatory and requires assistance with daily living activities and had no pressure injuries and no history of pressure injuries. The department found (R1) resided in the facility from 7/24/21-1/29/22. During this time R1 was hospitalized for a fall that occurred at the facility on 12/4/21. The department reviewed hospital records and found no evidence of a pressure injury when R1 was hospitalized. The department was unable to find facility records to support R1 sustained a pressure injury or R1 developing a pressure injury while residing at this facility. Additionally, on 01/14/21, R1 was discharged from the hospital without a care plan for pressure injuries as R1 was not diagnosed with a pressure injury while hospitalized.

Allegation #5: Facility are not providing residents with food of good quality.
The investigation revealed the following: Regarding the allegation: Facility staff are not providing residents with food of good quality, it is being alleged that resident #1 (R1) did not get receive food of good quality, resulting in malnutrition.
On 01/27/21, The department interviewed the Licensee Richard Smith (S1) and two residents (R1-R2). The department found 2 out of 2 residents were interviewed and stated that they eat three meals daily, never deprived of food and stated the food is terrific. The Department staff witnessed the residents enjoying their meals, while the licensee assisted in R1 & R2 with their meals.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 11-AS-20220125095503
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: SENIOR LIVING LIFESTYLE- PALOS VERDES
FACILITY NUMBER: 198601570
VISIT DATE: 11/02/2024
NARRATIVE
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Allegation #6: Staff are mismanaging resident’s medication.
Regarding the allegation, “Staff are mismanaging resident’s medication,” it is being alleged that Resident #1 (R1) did not receive the correct medication. The resident R1’s Physician’s Report (LIC 602A) dated 07/11/21 revealed that R1 cannot self-care and requires assistance with activities of daily living and medication administration. The Department records review indicated that the facility consistently assists with administering medication to R1 since R1 was admitted at Senior Living Lifestyle—Palos Verdes on 07/24/21. According to the Identification and Emergency Information (dated 07/11/21). The Department records reviews dated 07/12/21 to 01/20/22, indicated no mismanagement on the Medication Administration Record (MAR). The Department did not observe any discrepancy. There is insufficient evidence to support the allegation of staff mismanaging resident’s medication.

During this investigation, the Department did not find sufficient evident to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.


An exit interview was conducted, and a copy of the Complaint Report was given to Robert Smith /Licensee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9