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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602263
Report Date: 07/19/2024
Date Signed: 07/19/2024 11:55:17 AM

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
03/03/2022 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20220303154749
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:
07/19/2024
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Krystal AdamsTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident lost part of his finger while in care.
INVESTIGATION FINDINGS:
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On 07/19/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to render findings of the allegations listed above. LPA Richard met with Krystal Adams and the purpose of today’s visit was explained.


The investigation consisted of the following: On 03/04/2022, LPA Jose Calderon initiated an unannounced complaint investigation and requested records which included physicians report, needs and service plan, Physician Report, Medical report for the last 3 months, IPP, Kaiser hospital records, SIR reports. On 03/04/2022 the Department’s Investigations Branch (IB) resume the complaint investigation. On 08/16/2022 the investigation was completed by IB.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
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 6
Control Number 11-AS-20220303154749
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: NP CARE HOME
FACILITY NUMBER: 198602263
VISIT DATE: 07/19/2024
NARRATIVE
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Regarding the allegation: “Resident lost part of his finger while in care.”

It is being alleged that staff do not supervise residents resulting to resident getting injured while in care. IB interviews indicate the following: The administrator stated that on 03/01/2022 she was not present at the facility and the incident happened during a short 30-minute period when there were no other caregivers were present at the facility other than S1. Staff (S1) S1 stated that on 03/01/2022 around 2:40 pm S1 just laid R1 to bed for a nap and went to the kitchen to prepare dinner. After 20 minutes S1 heard a bump, she got to R1 room R1 was on the floor by the bed, and S1 discovered R1 left finger was bleeding and pieces of the skin was on the floor. R1 suffers from dementia and does not recall how they lost part their finger. R1 was transported to Kaiser Urgent Care and was treated for an injury sustained on the left hand. Record Reviews indicate the following: R1 Physician’s Report dated 01/18/2022 indicate that R1 is confused, is disoriented, has inappropriate and wandering behaviors. Hospital Medical Records indicate that R1’s injury to the left finger was a tear of the skin from the fingerprint to the tip of finger (tears typically caused by explosions, gunshots, and animal bites and industrial equipment injuries.) The medical records and the explanation provided by the facility staff on how they believe R1 sustained the injury was not consistent with the diagnosis provided by medical staff on how R1 got injured.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20220303154749
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: NP CARE HOME
FACILITY NUMBER: 198602263
VISIT DATE: 07/19/2024
NARRATIVE
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The preponderance standard has been met, therefore, the allegation “Resident lost part of his left finger while in care” is substantiated. California Code of Regulations, Tittle 22, Division 6, and Chapter 8 are being cited.

Please see LIC9099D.

Exit interview was conducted and plan of correction was developed with the Administrator. A copy of this report and Appeals Rights was provided .

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20220303154749
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: NP CARE HOME
FACILITY NUMBER: 198602263
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2024
Section Cited
CCR
87461(a)(1-2)
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87461(a) (1-2) Mental Condition. The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual:(1) tends to wander; (2) is confused or forgetful; this requirement was not met as evidenced by:
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The licensee will create a plan to ensure that amount of supervision is determined and provided based on the residents needs. Proof of correction will be submitted to LPA Richard before POC Due Date. 07/22/24. Antonine.Richard@dss.ca.gov
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Based on interviews and record reviews, the facility did not provide supervision necessary for R1 on 03/01/2022 resulting in R1’s injuries, this poses an immediate health, safety, and personal rights risk to residents 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: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
03/03/2022 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20220303154749

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:
07/19/2024
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Krystal AdamsTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
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9
Resident has a laceration under his eye.
INVESTIGATION FINDINGS:
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On 07/19/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to render findings of the allegations listed above. LPA Richard met with Krystal Adams and the purpose of today’s visit was explained.


The investigation consisted of the following: On 03/04/2022, LPA Jose Calderon initiated an unannounced complaint investigation and requested records which included physicians report, needs and service plan, Physician Report, Medical report for the last 3 months, IPP, Kaiser hospital records, SIR reports. On 03/04/2022 the Department’s Investigations Branch (IB) resume the complaint investigation. On 08/16/2022 the investigation was completed by IB.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20220303154749
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: NP CARE HOME
FACILITY NUMBER: 198602263
VISIT DATE: 07/19/2024
NARRATIVE
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Regarding the allegation: Resident has a laceration under the eye.

It is being alleged that residents are being physically abused while in care. IB Interviews indicate the following: Staff S1 stated that on 03/01/2022 around 2:40 pm that S1 just laid resident R1 to bed for a nap and went to the kitchen to prepare dinner. After 20 minutes S1 heard a bump, when S1 got to R1’s room R1 was on the floor by the bed and discovered R1 has a laceration under the left eye. Then S1 contacted the administrator and informed her about what happened, she instructed S1 to take R1 to Kaiser Urgent Care. R1 suffers from dementia and does not recall anything that happened or how R1 sustained a laceration under the left eye. The administrator and staff all stated that they checked for objects that could possibly cause the laceration under R1’s left eye. There were none observed. 2 out of 2 residents did not disclose any physical abuse by staff members or experiencing any abuse themselves. Record reviews indicate the following: Hospital medical records obtained during the investigation; notes that the laceration near left eye is a healing wound.

Based on IB, interviews, records reviews, and medical information available there was not enough evidence to support the 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.

Exit interview was conducted. A copy of the report was provided to the Administrator Krystal Adams.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6