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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603550
Report Date: 01/14/2025
Date Signed: 01/14/2025 02:33:35 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2024 and conducted by Evaluator Bennette Pena
COMPLAINT CONTROL NUMBER: 28-AS-20241211100006
FACILITY NAME:WEST PARK SENIOR LIVINGFACILITY NUMBER:
198603550
ADMINISTRATOR:CRYSTENE CHARFACILITY TYPE:
740
ADDRESS:801 CYPRESS WAYTELEPHONE:
(909) 592-8844
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:200CENSUS: 105DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Claudia Ruiz - Business Office ManagerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not provide residents with housekeeping services.
Staff do not ensure that the facility is maintained clean.
Staff do not ensure that passage way is free from obstruction.
Facility smells malodorous.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent visit in response to the above-mentioned allegations. LPA met with Claudia Ruiz, Business Office Manager and explained the reason for the visit.

Investigation consisted of the following: On 12/17/2024, LPA D. Konishi requested a copy of staff and resident rosters. During today's visit, LPA Pena obtained a copy of the staff & resident rosters, House rules, Housekeeping schedule and Resident #1 (R1) files such as; Admission Agreement, Identification & Emergency Information, Physician Report and Needs and Services Appraisal. LPA conducted a tour of the facility focusing on the hallways, laundry room, storage/trash room, 1st floor stairwell, 7th floor hallway, and (14) random residents rooms including room #s 709 & 721. LPA conducted interviews with Resident #2 (R2) - Resident #14 (R14) and Staff #1 (S1) - Staff #5 (S5) and telephonically interviewed Resident #1 (R1). *****CONTINUED ON LIC 9099-C*****
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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 28-AS-20241211100006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WEST PARK SENIOR LIVING
FACILITY NUMBER: 198603550
VISIT DATE: 01/14/2025
NARRATIVE
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 In regards to the allegation: “Staff do not provide residents with housekeeping services and Staff do not ensure that the facility is maintained clean .” It is alleged that the garbage cans in the hallways, inside of the laundry room and in the storage closet are not emptied and the flooring on the 7th floor is never swept or mopped. Interviewed staff denied the allegation and stated that housekeepers complete a list of their daily and weekly housekeeping duties. LPA toured the facility including the hallways, laundry rooms, storage/trash rooms, 1st floor stairwell, 7th floor hallway, and random and specific residents rooms. (2) housekeepers were observed cleaning the residents bedrooms and bathrooms. The facility appeared clean at the time of the visit. Interviews conducted with staff and residents did not corroborate the allegation. Based on the information obtained, the allegation is unsubstantiated.

In regards to the allegation: "Staff do not ensure that passage way is free from obstruction." It is alleged that the 1st floor stairwell has mildew, rags, cans of paint rags and wood stored in it. Interviewed staff denied the allegation. S1-S2 stated that a 3rd party contractor work on some of the resident bedrooms for updating but they take their equipment and supplies in the rooms where they are working. Staff interviewed denied seeing any items in the 1st floor stairwell. (13) out of (14) residents interviewed indicated that they did not see the 1st floor stairwell with mildew or other obstructing items. Interviews conducted with staff and residents did not corroborate the allegation. During the tour, LPA did not observe any items like rags, cans of paint rags, wood or mildew in the 1st floor stairwell. Based on observation and information obtained, the allegation is unsubstantiated.

In regards to the allegation: "Facility smells malodorous." It is alleged that room #709 smells "like funk and the facility smells like "urine and funk." Staff interviewed denied the allegation and stated that the residents in the 7th floor are all independent living and manage their own housekeeping. (5) out of (5) staff interviewed stated that they never smelled urine or funk in the room. (13) out of (14) residents interviewed also denied the allegation and indicated that they never smelled any room in any floors like urine and funk. During the tour, LPA observed that there's a cat in a specific room but it did not smell malodorous. LPA did not observe urine on the walls or on the floor on the specific resident's room during the visit. Based on the observation and information obtained, the allegation is unsubstantiated.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2024 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241211100006

FACILITY NAME:WEST PARK SENIOR LIVINGFACILITY NUMBER:
198603550
ADMINISTRATOR:CRYSTENE CHARFACILITY TYPE:
740
ADDRESS:801 CYPRESS WAYTELEPHONE:
(909) 592-8844
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:200CENSUS: 105DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Claudia Ruiz - Business Office ManagerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not maintain facility free from mold.
INVESTIGATION FINDINGS:
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In regards to the allegation: Staff do not maintain facility free from mold. It is alleged that room #721 has a moldy air conditioner. No other details provided. S1 stated that all residents in the 7th floor are independent living residents who manage their own housekeeping. R14 who is currently residing in the specific room indicated that the old air conditioning was moldy and dusty when he moved in. R14 stated that when he turned the a/c on, all the dust came out and gave him allergy. However, the air conditioning has been replaced with a new unit. Although LPA observed a new air conditioning in the room during the visit, the photos of the old air conditioning provided by R14 showed that it was dusty and moldy.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to Claudia Ruiz, Business Office Manager along with the Appeals Rights.


Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20241211100006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WEST PARK SENIOR LIVING
FACILITY NUMBER: 198603550
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Administrator will ensure that the facility continues to have inspections for mold or mildew in the residents rooms and provide LPA a written statement stating the plan on how to avoid the issue in the future by POC due date.
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Based on observation, interviews, records review, the Administrator did not comply with the section cited above in which LPA's observation and resident/staff interviews revealed that the air conditioning in Room #721 was replaced because of mold which poses a potential health and safety 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4