191222083-8-30-2023-29-AS-KHEN-CX4QCP-20231030120326

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191222083
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:54:38 PM

Unsubstantiated

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
01/03/2023 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20230103143807

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: 26	DATE:	08/30/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Gabriela Visovan, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff failed to have complete medical records on file.
Staff did not observe resident's change in condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at this facility. At 9:30 a.m., the LPA met with staff and explained the reason for the visit. At 9:55 a.m., the Administrator arrived at the facility.

During the initial visit on 01/12/2023, between 10:33 a.m. and 12:45 p.m., the LPA conducted interviews with four (4) staff interview, five (5) resident interview and with the Administrator. The LPA also conducted a brief physical plant tour to ensure there are no health and safety hazards. During the initial visit, the LPA requested pertinent documents. Additionally, on 01/12/2023 at 12:17 p.m., the LPA conducted an interview with a Resident #1 (R1)’s family member. On 02/07/2023, the LPA conducted a file review of R1’s documents. During todays visit, at 10:21 a.m., the LPA conducted a physical plant tour.

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: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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-20230103143807

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: 08/30/2023

NARRATIVE

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Regarding the allegation: Staff failed to have complete medical records on file. On 01/03/2023, the Department received a complaint alleging that while the paramedics were at the facility for Resident #1 (R1) that staff did not have R1’s completed medical record or knowledge of R1’s medical history on hand. During the interview with the Administrator, it was revealed that resident files are located in two (2) areas throughout the facility. The original copies of resident files are located in the Administrators office and copies of the original files including residents’ physicians report are located in the medication room. The Administrator explained that staff have access to both areas. Interviews with Staff #1 (S1) revealed that when the paramedics are at the facility, that S1 typically goes to the medication room and makes copies of the residents file for the paramedics. S1 stated that sometimes if a file isn’t complete, they go to the Administrators office to complete the file. The Administrator explained that if the residents file isn’t complete in the medication room that it is complete in the Administrator office. On 01/12/2023, the LPA received a copy of R1’s file. On 02/07/2023, the LPA reviewed R1’s file and observed the file to be in compliance and complete. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff did not observe resident's change in condition. On 01/03/2023, the Department received a complaint alleging that staff did not observe R1’s change in condition within the past few days prior to R1’s hospitalization on 01/03/2023. The complainant believed that R1 had sepsis and that staff did not notice the symptoms of sepsis. During the interview with the Administrator, she stated that when caregivers conduct body checks or are assisting residents, that they always report back to the Administrator if a resident presents any changes or change of condition. The Administrator said that the caregivers constantly communicate with her regarding R1’s condition. The Administrator said that R1’s family member visits R1 twice a week and she constantly communicates with R1’s family member about R1’s condition and well-being. The Administrator said that if R1 has a change of condition, that she notifies R1’s responsible person and R1’s doctor. Interview with R1’s family member revealed that the Administrator and caregivers always update and communicate with R1’s family member about R1’s condition and well being. R1’s family member did not voice any concerns regarding R1’s care and supervision at the facility.

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: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230103143807

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: 08/30/2023

NARRATIVE

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Additionally, a file review conducted by the LPA revealed that the Administrator faxed an Unusual Incident/ Injury Report to the Department on 01/05/2023 regarding R1’s hospitalization on 01/03/2023. The incident report described that on 01/03/2023, staff noticed R1’s right side of the face being droopy and right eye closed. Staff called 911 and R1 was transported to the hospital. Per the incident report, staff did notice a change in condition of R1 which they proceeded to call 911. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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