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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601899
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:25:46 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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2021 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20210308091404
FACILITY NAME:JEFFERSON MANORFACILITY NUMBER:
198601899
ADMINISTRATOR:JOSEFINA GUIAOFACILITY TYPE:
740
ADDRESS:1662 W. JEFFERSON BLVD.TELEPHONE:
(213) 880-5505
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY:6CENSUS: 4DATE:
07/22/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Czarina DorotanTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident was hospitalized due to staff neglect
INVESTIGATION FINDINGS:
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On 07/22/21 Licensing Program Analyst Jade Jordan conducted a subsequent visit to deliver findings in regards to the above allegation. LPA met with Administrator Assistant Czarina .

Regarding Allegation: Resident was hospitalized due to staff neglect
Complaint investigation was referred to Investigations Branch (IB). It was revealed during their investigation that on 03/03/21 Resident 1 (R1) was Lethargic, but vitals were within the normal range. On 03/04/21 condition was similar as the day before. According to Facility Log On 03/04/21, at 6:59 am R1’s temperature was measured at 99.1F. R1 Vitals were checked again at 14:35hrs same day, and Facility staff Measured R1’s Blood pressure at 78/48 which they considered low. Facility staff were unable to obtain an oxygen saturation reading for R1. Therefore; 911 was called. Paramedics arrived shortly and transferred R1 to the hospital. Upon arrival, the hospital determined R1 was Hypothermic. On 03/04/21, R1 was diagnosed with numerous other medical conditions; including testing positive for Covid 19.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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 11-AS-20210308091404
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: JEFFERSON MANOR
FACILITY NUMBER: 198601899
VISIT DATE: 07/22/2021
NARRATIVE
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The hospital was concerned that R1 could’ve been Hypothermic around 6am on 03/04/21, due to Handwritten Vitals observed on the back of some paperwork that accompanied R1 to the hospital. Reporting Party (RP) was unable to provide information of where the observed handwritten vitals were located, nor was there a copy of handwritten vitals to provide to the investigator. RP was unable to recall what the temperature was on the note.

Investigations Branch (IB) investigator concluded that the information and evidence obtained during the investigation did not sufficiently support the allegation. The department agrees with Investigation Findings. Therefore; Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is unsubstantiated.


A copy of this report was given. No Citations were issued during this visit.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2