198602390-9-1-2021-11-AS-EMAZ-C7BVGC-20210929162520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602390
Report Date: 09/01/2021
Date Signed: 09/01/2021 04:06:17 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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2021 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20210827151400

FACILITY NAME:	DANIELLA'S HOME		FACILITY NUMBER:	198602390
ADMINISTRATOR:	COELLO, BESSIE L		FACILITY TYPE:	740
ADDRESS:	18005 OSAGE AVENUE		TELEPHONE:	(310) 371-4088
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 4	DATE:	09/01/2021
		UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Bessie Coelho-		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident sustained an injury from a fall while in care

INVESTIGATION FINDINGS:

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On 09/1/2021, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint visit at this facility. LPA met with Natalia Torres, House Manager and explained the purpose of today's visit is to conduct an investigation regarding the allegations listed above.

The investigation consisted of the following: LPA interviewed Administrator Bessie Coelho. Interviews were conducted with two (2) staff and four (4) residents (R1-R4). LPA inspected the facility. LPA reviewed records for residents 1-4 (R1-R4) along with the current staff/resident roster and other documents in association with the allegations.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210827151400

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
MONTERY PARK, CA 91754

FACILITY NAME: DANIELLA'S HOME	FACILITY NUMBER: 198602390
	VISIT DATE: 09/01/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Resident sustained an injury from a fall while in care

The complainant alleges that on 8/21/2021 R1 was found on bathroom floor and received an injury due to a fall. LPA Cifuentes reviewed incident report sent by facility for date 8/20/2021, that was faxed to Community Care Licensing. The report states that R1 was in bathroom with S1, when R1 called S1 to let them know something was occurring as they were voiding. S1 turned around to assist R1. Per incident report, R1 did not fall while in bathroom. LPA interviewed staff (S1) who was on shift the evening of the incident. Per S1, R1 did not fall, they were escorted to the bathroom by staff, who turned to give R1 privacy. R1 told S1 that something was wrong, so S1 immediately turned and took note of the situation and called 911. At no time during incident did R1 fall. Reporting parties’ statement is inconsistent with what was reported by S1 during interview as well as report on incident provided by facility to Community Care Licensing. LPA interviewed resident R1, who stated they had fallen but it was a long time ago. Interviews with administrator and S2 also indicate that while R1 is a fall risk, they did not sustain a fall in the bathroom on 8/21/2021 or on 8/20/2021.

Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of resident records, incident report, and interviews conducted and found no evidence to support the allegation: “Resident sustained an injury from a fall while in care”.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Bessie Coelho and a copy of the report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC9099 (FAS) - (06/04)

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