191222083-10-20-2020-29-AS-JAPL-BUSQF9-20201027120734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191222083
Report Date: 10/20/2020
Date Signed: 10/20/2020 11:44:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2020 and conducted by Evaluator Eva Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200813160409

FACILITY NAME:	LIGHTHOUSE, THE		FACILITY NUMBER:	191222083
ADMINISTRATOR:	GABRIELA VISOVAN		FACILITY TYPE:	740
ADDRESS:	10406 MAGNOLIA BLVD.		TELEPHONE:	(818) 766-3764
CITY:	TOLUCA LAKE	STATE: CA	ZIP CODE:	91601
CAPACITY:	49	CENSUS: 30	DATE:	10/20/2020
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Gabriela Visovan		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Failure to provide adequate care and supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Eva Miller conducted a subsequent complaint visit for the purpose of delivering the final determination of the investigation of the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint visit was conducted virtually with the use of "FaceTime" with Administrator Gabriela Visovan.

The complainant alleged that neglect and/or lack of supervision on the part of facility staff resulted in a diabetic resident’s healing surgical wound to become infected and subsequently infested with maggots. The investigation was conducted by Investigator Peter Zertuche (Badge #33) of the California Department of Social Services (CDSS), Community Care Licensing Division (CCLD) Investigations Branch (IB). The investigation is summarized as follows:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

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 29-AS-20200813160409

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LIGHTHOUSE, THE	FACILITY NUMBER: 191222083
	VISIT DATE: 10/20/2020

NARRATIVE

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On August 20, 2020, at approximately 10:00 a.m., Investigator Zertuche contacted and interviewed the complainant. On August 25, 2020, at approximately 1:00 p.m., a subpoena was served to the treating hospital for related medical records. On August 25, 2020, at approximately 2:00 p.m., a subpoena was served to the hospice agency for medical records. On August 26, 2020, at approximately 2:30 p.m., the Long-Term Care Ombudsman (LTCO) was contacted. On September 23, 2020, at approximately 1:00 p.m. Investigator Zertuche conducted an interview with the Hospice Care Director, as well as a follow-up interview on September 29, 2020, at approximately 4:45 p.m. On September 23, 2020, at approximately 2:00 p.m. an interview was conducted with the wound physician’s Practice Manager. On September 24, 2020 at approximately 1:00 p.m. and September 29, 2020 at approximately 4:30 p.m. interviews were conducted with facility personnel.

Based on the information obtained during the investigation it was determined that Resident #1 (R-1), while residing in the facility, was receiving medical care from Hospice Care Services and Visiting Medical Professionals. Facility personnel were not involved in the provision of any medical treatment. The medical condition of R-1 was observed to have exacerbated resulting in the hospitalization of R-1. The investigation did not reveal any evidence of neglect on the part of the facility personnel. The allegation is unsubstantiated.

A copy of the licensing report was provided to the Administrator for signature and return.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC9099 (FAS) - (06/04)

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