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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602263
Report Date: 06/23/2023
Date Signed: 06/23/2023 01:40:40 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
12/09/2022 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221209162052
FACILITY NAME:NP CARE HOMEFACILITY NUMBER:
198602263
ADMINISTRATOR:TATUM, RONICFACILITY TYPE:
740
ADDRESS:3767 VIRGINIA ROADTELEPHONE:
(323) 205-5145
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY:6CENSUS: 6DATE:
06/23/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Krystal Adams, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident sustained injuries from a fall while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Krystal Adams, Administrator

The investigation consisted of following: Interviews and Record reviews.On 06/23/23, LPA Soto interviewed R#1 - R#6. LPA Soto obtained residents file (Care services, Daily plan, Needs and Service Plan, Physician Reports, Preplacement appraisal, ID/Emergency Information, Admission Agreement, Mars for December 2022, SIR, and work schedule for December 2022.) On 05/30/23, LPA Soto conducted interviews with the S#1 - Administrator and S#4 & via telephone - S#5. LPA Soto also requested copies of the following documents: Resident and Staff rosters. On 12/14/22, LPA Alvizar interviewed Administrator, Staff S#2 - S#3, R#1 - R#2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
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 2
Control Number 11-AS-20221209162052
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: NP CARE HOME
FACILITY NUMBER: 198602263
VISIT DATE: 06/23/2023
NARRATIVE
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Received the following documents on 12/14/22: Copy of the resident complete facility file to include but not limited to Staff and Resident Roster, Needs and Service Plan for R#1, Physician Report for R#1, Medication list for R#1, SIR report R#1 and time sheets. LPA and Administrator toured the facility including 3 bathrooms, 4 bedrooms, dining room, living room and kitchen.

Based on the LPA's investigation, the investigation revealed the following.

Allegation – Resident sustained injuries from a fall while in care.
Interviews with S#1, S#4, & S#5, they communicated that the resident's fall was un-witnessed. Resident was found by S#5 around 7am when their shift began. S#5 was checking in on the residents going to get them ready for the day. The resident was on the floor with residents head bleeding, but responsive. Resident was opening their eyes. S#5 communicated that S#5 asked resident what had happened and why did resident try to get out of bed on their own. Resident only looked at S#5 and stated that resident did not know what had happened. S#5 called Administrator and 911, the resident was taken to the E.R. Resident's bed had the half rails up and they are not sure how the resident got out of bed. The resident had never done that before, resident had always waited for assistance to get out of bed. Staff #3 that was working that night, did not hear, see or was aware that the resident had fallen. Staff member was taking care of another resident at the time of the incident. The last time staff #3 checked on resident was that morning around 6:40am to 6:45am and they were fine in their bed. Interviews with R#1, R#2, R#3, R#4, and R#6, communicated that they have never fallen or witnessed any other resident fall. R#5, communicated that they were the residents roommate, they shared the room. R#5, only heard the fall, but did not witness the fall. R#5, believes that there was no staff member in the room at the time of the fall. R#5, believes they were alone, but they are not too sure because the rails were up on their bed and the rails obstructed their view. LPA Soto reviewed resident physician's report dated 05/14/21, resident required assistance with all their ADL's and was diagnosed with Dementia. Resident could walk, but with assistance from the staff. LPA reviewed resident's Daily schedule, resident was given a bed alarm to be placed on resident bed rails to go off when resident moved out of bed. Resident's family provided the alarm. S#1 communicated that the alarm had broken about 6 months prior to the incident and they informed the family, so they could replace the alarm but family never replaced the alarm for their resident. Interviews and records review did not concur with the above allegation.
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 with Krystal Adams, Administrator, and a hard copy of report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2