<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005743
Report Date: 11/08/2023
Date Signed: 11/08/2023 12:00:17 PM

Unfounded


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
10/06/2023 and conducted by Evaluator Jessica Cho
COMPLAINT CONTROL NUMBER: 22-AS-20231006142559
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: 5DATE:
11/08/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Theresa Dompreh-Mensah- AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that resident's mental health needs were met.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jessica Cho arrived unannounced and met with Administrator (Admin) Theresa Dompreh-Mensah for the purpose of continuing the investigation and delivering the findings into the above allegation. LPA explained the reason for the visit and reviewed the allegation with Admin Dompreh-Mensah.

On October 10, 2023, LPA initiated the complaint investigation which involved interviews with residents and staff and obtaining pertinent resident records. On today's date, LPA continued the investigation and conducted additional interviews with resident/staff and obtained a missing record that was not provided during the initial visit. The following was determined based on the evidence obtained:

It is alleged that the staff did not ensure that the resident’s mental health needs were met. It was noted on the Special Incident Reports (SIRs) and Progress Notes that Resident #1 (R1) expressed homicidal ideations towards Resident #2 (R2) on two occasions: September 12th and September 29th, 2023.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
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-20231006142559
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: 11/08/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
R1 made an admission during the interview that Staff #1 (S1) did not interfere with the Crisis Assessment Team’s (CAT) ability to conduct an evaluation due to R1’s homicidal ideations. S1 did not corroborate with the allegation. Two out of the two witnesses who were present during the evening of the second incident, September 29, 2023, indicated that the CAT was allowed entry into the facility and was not intervened by S1.

Therefore, this agency has investigated the complaint and based on the interviews which were conducted and the records that were reviewed, the following allegation: Staff did not ensure that the resident’s mental health needs were met is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Administrator Theresa Dompreh-Mensah, and a copy of this report including the LIC811s were provided at the end of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
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
10/06/2023 and conducted by Evaluator Jessica Cho
COMPLAINT CONTROL NUMBER: 22-AS-20231006142559

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: 5DATE:
11/08/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Theresa Dompreh-Mensah- AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff threatened resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jessica Cho arrived unannounced and met with Administrator (Admin) Theresa Dompreh-Mensah for the purpose of continuing the investigation and delivering the findings into the above allegation. LPA explained the reason for the visit and reviewed the allegation with Admin Dompreh-Mensah.

On October 10, 2023, LPA initiated the complaint investigation which involved interviews with residents and staff and obtaining pertinent resident records. On today's date, LPA continued the investigation and conducted additional interviews with resident/staff and obtained a missing record that was not provided during the initial visit. The following was determined based on the evidence obtained:

It is alleged that the staff threatened the resident. It was noted on the Special Incident Reports (SIRs) and Progress Notes that Resident #1 (R1) expressed homicidal ideations towards Resident #2 (R2) on two occasions: September 12th and September 29th, 2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
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-20231006142559
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: 11/08/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the interviews obtained from R1 and Staff #1 (S1), there were conflicting details, therefore LPA is unable to corroborate the allegation.

Based on the interviews which were conducted and the records that were reviewed, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation: Staff threatened resident is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Theresa Dompreh-Mensah, and a copy of this report including the LIC811s were provided at the end of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4