191222083-3-18-2022-29-AS-KHEN-CCRVNN-20220322163526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191222083
Report Date: 03/18/2022
Date Signed: 03/18/2022 02:16:22 PM

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
08/21/2020 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20200821132223

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: 24	DATE:	03/18/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Gabriela Visovan, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff physically abused resident.
Staff denied resident food and water.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver findings for the above allegations. At 12:20 p.m., LPA met with Administrator, Gabriela Visovan and explained the reason for the visit.

Regarding the allegation: Staff physically abused resident.

On 08/21/2020, the Department received a complaint regarding Physical Abuse. Resident #1 (R1) was admitted to the hospital with bruising on left hand and both arms. R1 stated the facility staff “bang” on her. On 08/24/2020, the complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Edward Hector.

Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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 29-AS-20200821132223

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: 03/18/2022

NARRATIVE

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Continued from LIC 9099.

On 08/24/2020, from 12:30pm to 1:22pm, Licensing Program Analyst (LPA) Desaree Perera conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint visit was conducted via FaceTime with Administrator Gabriela Visovan. During the visit, LPA Perera conducted a virtual physical plant tour at 12:37pm. LPA also conducted an interview with Administrator and requested documentation pertinent to the allegations at 12:50pm. No immediate health and safety concerns were noted. LPA determined further investigation was required.

On 09/10/2020, at 8:55am, Investigator Hector reviewed facility documents related to R1. According to the Physician Report dated 03/13/2018, R1 had a history of skin condition or breakdown, specifically, pressure injuries. R1 had a high capacity for self-care that included being able to feed, toilet, bathe and dress self; manage own cash resources independently; conduct grooming with assistance; and able to independently transfer to and from bed. According to the Appraisal Needs and Services Plan dated 06/12/2020, R1 was described as “unhappy with everything and everyone”. It also stated R1 was abusive towards all staff. According to a hospital assessment involving R1’s emotional/psychological health, R1’s representative reported that R1 accuses “others of stealing belongings” that are later found to be in R1’s room and R1 “accuses others of poisoning R1”. R1’s representative said they are skeptical of any abuse reported because, when R1 “doesn’t want to cooperate R1 will claim that R1 is being abused”.

On 11/25/2020, from 8:50am to 9:30am, Investigator Hector conducted interviews with the Long-Term Care Ombudsman (LTCO); at 9:59am, left a voicemail for the reporting party; at 10:25am, with the Los Angeles Police Department (LAPD) North Hollywood Community Police Station; on 12/01/2020, at 9:34am, attempted to contact the reporting party, voicemail full/unable to leave message; at 11:56am, with the reporting party; at 12:07pm, with R1’s primary care physician; and from 2:50pm to 3:08pm, with facility residents and Administrator.

Continued on LIC 9099-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20200821132223

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: 03/18/2022

NARRATIVE

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According to the medical records, R1 was transported via ambulance to the Providence Saint Joseph Medical Center on 08/17/2020, at 5:38pm, for the chief complaint of “weakness”. During the assessment the nurse denied seeing signs of abuse, the MD confirmed no signs of abuse found. The medical records listed R1’s overall behavior as noncompliant. More specifically, the records describe R1 as “alert, very rude and hitting caregivers, spitting meds, refused to eat in spite encouragement”. R1 was observed to have multiple skin issues. However, when hospital staff attempted to do wound care, R1 refused. The nurse noted R1 had no bruising. R1 presented to the hospital with Stage 1 pressure injuries on posterior medial coccyx and upper posterior back and Stage 2 pressure injuries on right ischial tuberosity and upper lateral scapula. R1 also had other wounds of dryness and scaling of leg and moisture damage wounds near the groin and buttocks area. R1 was also diagnosed with dehydration and a Urinary Tract Infection (UTI). However, the records indicate R1 refused food and meds from hospital nurses. R1 also tested positive for the COVID-19 virus. R1 was discharged on 08/24/2020.

R1 returned to the hospital on 08/26/2020 and was diagnosed with UTI, still tested positive for the COVID-19 virus, severe protein-calorie malnutrition condition, and a Stage 1 pressure injury on left heel. The physician noted R1 had altered mental status and lethargic. Progress notes listed that the readmission within the last 30 days was due to the previous discharge plan was unsuccessful. The medical staff met with R1’s representatives to review R1’s overall health. Hospital staff reviewed potential causes of R1’s altered mental status could possibly be attributed to testing positive for COVID-19 or due to UTI. The hospital staff also advised that the altered mental status may possibly be attributed to R1 approaching the end of life and would need 24-hour care. As a result, the hospital staff recommended R1 be placed on Hospice care. R1 was discharged on 09/01/2020.
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According to the medical records, the doctors and nurses noted no signs of abuse. Furthermore, R1’s primary care physician confirmed R1’s bruising was attributed to “fragile” skin. The physician also had no concerns of rough handling by the facility staff.

Based on the information obtained, the Department does not have sufficient evidence to support the above allegation. Therefore, the above allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20200821132223

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: 03/18/2022

NARRATIVE

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Continued from LIC 9099-C.

Regarding the allegation: Staff denied resident food and water.

On 08/21/2020, it was alleged that the staff denied food and water to resident. During the initial visit, conducted virtually to implement mitigation measures related the Coronavirus Disease 2019 (COVID-19) on 03/25/2020, LPA Desaree Perera conducted a virtual physical plant tour, and interviewed the Administrator and requested pertinent files and documents between 12:30 p.m. and 1:22 p.m. On 03/18/2022 at 12:20 p.m., LPA Peraldi conducted a subsequent complaint visit. At 12:26 p.m., LPA Peraldi conducted a physical plant tour. Between 12:27 p.m., and 1:12 p.m., LPA Peraldi interviewed five (5) out of twenty-four (24) residents. Additionally, between 12:40 p.m. and 1:30 p.m., LPA Peraldi interviewed two (2) staff and the Administrator. At 12:30 p.m., LPA Peraldi observed residents eating in the dining area. Interviews with residents and staff revealed that the facility has an accessible water fountain that dispenses filtered hot and cold water. At 1:34 p.m., LPA Peraldi observed the water fountain located outside in the patio. Additionally, interviews with residents revealed that the facility does not deny residents of food and water.

Based on the information obtained, the Department does not have sufficient evidence to support the above allegation. Therefore, the above allegation is deemed Unsubstantiated at this time.

Exit interview conducted with Administrator. A copy of the report and appeal rights will be provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

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