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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601665
Report Date: 07/07/2021
Date Signed: 07/07/2021 12:55:34 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/24/2020 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201224134008
FACILITY NAME:ELEGANT CARE INC.FACILITY NUMBER:
198601665
ADMINISTRATOR:JEWEL REESEFACILITY TYPE:
740
ADDRESS:834 E. 74TH ST.TELEPHONE:
(323) 821-1601
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY:6CENSUS: 5DATE:
07/07/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jewel Reese, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff mismanaged resident's medication resulting in hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan initiated a subsequent complaint investigation for the allegation – Facility staff mismanaged resident’s medication resulting in hospitalization. LPA arrived at 10:30 a.m. and met with Staff, Stacey Thomas. Administrator, Jewel Reese, arrived at 10:50 a.m. The purpose of the visit was explained.

The investigation consisted of the following:

On 12/31/2020, LPA Chan conducted the initial visit telephonically. LPA interviewed the Administrator and requested copies of Staff and Resident rosters and documents pertaining to Resident #1: Physician's Report, hospital discharge documents, Medication Log from October through December 2020, and the Appraisal Needs and Service Plan. On 7/7/21, LPA Chan interviewed 1 Staff and 4 Residents. Resident #1 passed away on 1/26/21 and was not interviewed.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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 28-AS-20201224134008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELEGANT CARE INC.
FACILITY NUMBER: 198601665
VISIT DATE: 07/07/2021
NARRATIVE
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The investigation revealed the following:

In regards to allegation – Facility staff mismanaged resident’s medication resulting in hospitalization in December 2020. Administrator Reese denied mismanaging residents’ medications. She stated that every time residents take their medication, it is marked on the medication log. If a resident refuses to take the medication, the reason will be noted on the back of the log. LPA Chan reviewed Resident #1’s (R1) Medication Administration Record (MAR) from October through December 2020 and did not find any discrepancies. Per Administrator and Staff, R1 was medication compliant and had taken all the medications prescribed by the physician. During the visit today, LPA interviewed 4 residents who all stated that the staff are nice and help with their needs. 2 out of the 4 interviewed are taking medications and both stated that they take their medications daily.



Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted and a copy of this report along with appeal rights were given to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2