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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601704
Report Date: 03/03/2023
Date Signed: 03/03/2023 03:47:02 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
09/07/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220907154442
FACILITY NAME:HARMONY HOME CAREFACILITY NUMBER:
198601704
ADMINISTRATOR:DIONSIO, ANTONIAFACILITY TYPE:
740
ADDRESS:1318 215TH STREETTELEPHONE:
(310) 549-0218
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:6CENSUS: 6DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Elmer Carlos & Antonia DionsioTIME COMPLETED:
03:59 PM
ALLEGATION(S):
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Resident sustained an injury while in care.
INVESTIGATION FINDINGS:
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On 03/03/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent visit to the facility and was greeted by care staff (S1: Elmer Carlos). LPA spoke to (S1) prior to entering the facility to conduct a risk assessment. (S1) informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. Carlos contacted administrator (S2: Antonia Dionsio) by telephone who later arrived at the facility.

The investigation consisted of the following:LPA Dabuet conducted the 10-day visit on 09/09/22 with Administrator Dionsio. LPA toured the facility with Administrator and requested copies of the following documents: facility staff and resident rosters; Admission Agreement, Appraisal/Needs and Services Plan, Physician’s Report, medical records (to include hospital records) Medication Administration Records and Unusual Incident/Injury Report for Resident #1. (Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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 5
Control Number 11-AS-20220907154442
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: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 03/03/2023
NARRATIVE
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A separate investigation was conducted by the Department of Social Services, Investigator Lorraine Patterson that included a review of hospital medical records, interview with witness, facility staff, and facility residents.

INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: this investigation revealed that Resident #1 (R1) on 05/08/22 was taken by Emergency Medical Services to Harbor UCLA Medical Center due to sustaining an unwitnessed fall. At the hospital, (R1) was found with a right frontal hematoma. Images of Computed Tomography (CT) revealed a large left hemispheric subdural hemorrhage. Medical reports revealed it was uncertain if (R1’s) fall was due to an abstract fall or a loss of consciousness for short period. The abuse screen revealed elder/dependent abuse present was “no”. (R1’s) subdural hematoma was managed conservatively and was discharged back to care at this facility on 05/14/22. The reporting party/witness #1 (W1) denied neglect or abuse led to (R1’s) fall and added that (R1) was not a fall risk. (R1) did not have a history of falls from a prior residential care facility. However, (W1) remained concerned that (R1) had limited exercise at this facility. The investigator was informed by (W1) and (S1) that (S1) provided care to (R1) minutes before (R1) fell. (S1) denied neglect or abuse and insisted (R1) did not have a history of falling, and that (R1) was at baseline when the unforeseen fall happened. Records reviewed and interviews witness, care staff and residents interviews did not corroborate the allegation of neglect or elder abuse led to (R1) sustaining an injury in care.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: “Resident sustained an injury while in care” is unsubstantiated.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/07/2022 and conducted by Evaluator Ernand Dabuet
COMPLAINT CONTROL NUMBER: 11-AS-20220907154442

FACILITY NAME:HARMONY HOME CAREFACILITY NUMBER:
198601704
ADMINISTRATOR:DIONSIO, ANTONIAFACILITY TYPE:
740
ADDRESS:1318 215TH STREETTELEPHONE:
(310) 549-0218
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:6CENSUS: 6DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Elmer Carlos & Antonia DionsioTIME COMPLETED:
03:59 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility staff did not seek out timely medical attention for resident in care.
INVESTIGATION FINDINGS:
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5
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13
On 03/03/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent visit to the facility and was greeted by care staff (S1: Elmer Carlos). LPA spoke to (S1) prior to entering the facility to conduct a risk assessment. (S1) informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. Carlos contacted administrator (S2: Antonia Dionsio) by telephone who later arrived at the facility.

The investigation consisted of the following:LPA Dabuet conducted the 10-day tele-visit on 09/09/22 with Administrator Dionsio. LPA toured the facility with Administrator and requested copies of the following documents: facility staff and resident rosters; Admission Agreement, Appraisal/Needs and Services Plan, Physician’s Report, medical records (to include hospital records) Medication Administration Records and Unusual Incident/Injury Report for Resident #1. (Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20220907154442
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: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 03/03/2023
NARRATIVE
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A separate investigation was conducted by the Department of Social Services, Investigator Lorraine Patterson that included a review of hospital medical records, interview with witness, facility staff, and facility residents.

INVESTIGATION REVEALED THE FOLLOWING:

Allegation #3: this investigation revealed (S1) admitted on 05/08/22 when he discovered (R1) sustained an unwitnessed fall resulting in an injury, (S1) telephone the (W1) of his observations before calling Emergency Medical Services (EMS). (S1) further admitted that on 05/23/23 during (W1’s) visit, (S1) was put on noticed about (R1) not moving the right arm. (S1) admitted (EMS) was not contacted until (W1) left the facility and returned with a family to further assess (R1’s) condition. Based on records reviewed and interviews conducted with witness and care staff did revealed evidence to corroborate neglect/failure to seek timely medical attention.

Based on the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/FAILURE TO SEEK TIMELY MEDICAL ATTENTION: “Facility staff did not seek out timely medical attention for resident in care” is substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099-D).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20220907154442
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: HARMONY HOME CARE
FACILITY NUMBER: 198601704
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
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...

This requirement is not met as evidenced by:
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Licensee/Administrator shall read Title 22, Section 87466 “Observation of the Resident” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 03/17/23.
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Based on interview and record reviews, (S1) admitted such changes in (R1’s) health condition failed to seek timely medical attention on 05/08/23 and 05/23/22, which poses a potential health and safety risk to residents in care.
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*Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until POCs are cleared.*
Type B
03/17/2023
Section Cited
CCR
87405
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87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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Licensee/Administrator shall read Title 22, Section 87405(b)(2) “Administrator - Qualifications and Duties” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 03/17/23.
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This requirement was not met as evidenced by:
Based on interview and record reviews the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.
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*Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until POCs are cleared.*
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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5