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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005743
Report Date: 09/14/2023
Date Signed: 09/14/2023 10:52:39 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230907145157
FACILITY NAME:ASSURED CARE VILLAFACILITY NUMBER:
306005743
ADMINISTRATOR:DOMPREH-MENSAH, THERESAFACILITY TYPE:
740
ADDRESS:561 EAST SECOND AVETELEPHONE:
(310) 650-4190
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 4DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Naomi Mensah and Theresa Dompreh-MensahTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Uncleared staff provided care to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the visit, LPA toured the facility and interviewed staff and residents. Regarding the allegation that uncleared staff provided care to residents, the investigation revealed the following: Staff (1) was present at the facility from 08/26-08/30/2023 while in the exemption process for background clearance. Facility received notification of exemption needed on 06/19/2023 with another notification for additional information on 08/25/2023. S1 was not approved by the Care Provider Management Bureau to be working, volunteering, or present at the facility while the exemption was pending. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was emailed to facility administrator along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
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 4
Control Number 22-AS-20230907145157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ASSURED CARE VILLA
FACILITY NUMBER: 306005743
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2023
Section Cited
CCR
87355(e)(1)
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All individuals subject to a criminal record review pursuant ... shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This req is not being met as evidenced by.
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Licensee to provide a written statement that S1 will not be present/ working at the facility. Licensee has disassociated S1 from the roster. Licensee to respond by POC due date.
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Based on interview and record review, Licensee failed to ensure S1 had background clearance prior to being present at the facility. S1 was in exemption process and had not received approval prior to being at the facility. Thisn poses an immediate 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230907145157

FACILITY NAME:ASSURED CARE VILLAFACILITY NUMBER:
306005743
ADMINISTRATOR:DOMPREH-MENSAH, THERESAFACILITY TYPE:
740
ADDRESS:561 EAST SECOND AVETELEPHONE:
(310) 650-4190
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 4DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Naomi MensahTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff do not meet residents' dietary needs
Staff do not meet resident's incontinence needs
Staff do not provide residents with activities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the visit, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as activity schedule and facility menu. Regarding the allegations that staff do not provide residents with activities, staff do not meet resident's incontinence needs, and staff do not meet residents' dietary needs, the investigation revealed the following: During the visit, LPA observed ample activity supplies such as games and magazines and observed one resident playing a game. Three out of four residents stated preferring their own personal activities to group activities. Staff indicate taking residents on walks outside as well. Four out of four residents use the toilet during the day and briefs at night. All residents interviewed denied any issues with incontinence care and state being properly cared for by facility staff. LPA observed an ample healthy food supply including fresh fruits, vegetables and meats. Four out of four residents verbalized satisfaction with quality of food served. LPA did not observe any food improperly stored. CONTINUED ON LIC 9099C DATED 09/14/2023....
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
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 22-AS-20230907145157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ASSURED CARE VILLA
FACILITY NUMBER: 306005743
VISIT DATE: 09/14/2023
NARRATIVE
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LPA observed ample emergency food and water as well. LPA observed no physician orders for any residents restricting dietary intake. Based on observations and interviews, the allegations are deemed UNFOUNDED, meaning the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was emailed to facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4