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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602263
Report Date: 11/02/2024
Date Signed: 11/02/2024 11:17:59 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 Alfonso Iniguez
PUBLIC
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:
11/02/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Pam Speights/Facility StaffTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident lost part of his finger and a laceration under eye while in care due to an unwitnessed fall.
INVESTIGATION FINDINGS:
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This complaint report supersedes the report completed on 7/19/24.


On 11/2/2024, Licensing Program Analyst, LPA Alfonso Iniguez conducted a subsequent complaint visit at the facility name above, LPA meet with Pam Speights/Facility staff and explained the purpose of the visit. The department found that on 7/19/2024 a civil penalty was not rendered, therefore, on today's visit a new citation with a civil penalty will be rendered.


Evaluation Report continues LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
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 4
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: 11/02/2024
NARRATIVE
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This complaint report supersedes the report completed on 7/19/24.

Investigation Revealed the Following:

Allegation: Resident lost part of his finger and a laceration under eye while in care due to an unwitnessed fall.

This complaint alleges the facility provided insufficient supervision for Resident # 1 (R1). The lack of supervision resulted in R1 sustaining a left finger injury and a laceration under the eye as a result of an unwitnessed fall. The department interviews with Resident (R1), Staff (S1), House Manager/ Crystal Adams (S2), and Administrator/Ronic Tatum (A1), indicate the following: On 03/01/22 2:40 PM, staff #1 (S1) stated she assisted R1 in R1’s wheelchair to R1’s bed for a nap. S1 then went to the kitchen. S1 stated approximately twenty minutes later, she heard a “thump” noise in R1’s room and went to check on R1. S1 stated she observed R1 had fallen and was on the floor near R1’s bed. S1 stated she observed R1’s hand was bleeding. S1 stated she then observed an injury on the dip to the tip of R1’s left 5th finger had sustained an avulsion injury and part of R1’s finger pad torn off. S1 stated she also observed a laceration under R1’s left eye.S1 stated she found the skin torn off of R1’s finger on the floor. S1 placed the skin in a bag and on ice to be taken to the hospital with R1. S1 stated R1 is a fall risk. The department conducted an interview with S2, who stated that on 03/01/2022, she left the facility to run errands when the incident occurred and was not present when R1 sustained injuries.

The department conducted an interview with A1 who confirmed S1 was working when R1 fell; however, she was unable to confirm any additional staff members were working when the incident occurred. A1 reported the facility census is (6) Residents. R1’s Family Member (W1) was contacted after the incident occurred and W1 transported R1 to Kaiser Permanente West Los Angeles Medical Center Urgent Care.

Evaluation Report continues LIC 9099-C...

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 11/02/2024
NARRATIVE
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This complaint report supersedes the report completed on 7/19/24.

The department found the facilities staffing was insufficient when this incident occurred as S1 was the only staff member working with (6) Residents when R1 fell and sustained significant injuries.

The preponderance standard has been met; therefore, the allegation is substantiated.

Deficiencies are being cited an the LIC9099-D. An immediate civil penalty of $500 is warranted accordance with California Health and Safety Code. See LIC421IM. Currently an enhanced civil Penalty determination is pending.

Exit interview was conducted and plan of correction was developed with the Administrator. A copy of this report and Appeals Rights was provided to Pam Speights/Facility Staff.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 11/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement was not met by:
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Licensee will ensure there is sufficient staff at all times. As plan of correction, licensee will come up with a plan to address when there is not sufficient staff available. Proof of correction will be email to LPA Richards before POC due date.
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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: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4