191290719-9-4-2024-31-AS-NMAN-D8Z4H7-20240910190639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290719
Report Date: 09/04/2024
Date Signed: 09/04/2024 02:38:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2024 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240411103116

FACILITY NAME:	MOTHER GERTRUDE HOME		FACILITY NUMBER:	191290719
ADMINISTRATOR:	SR. ELIA CARO		FACILITY TYPE:	740
ADDRESS:	11320 LAUREL CANYON BLVD		TELEPHONE:	(818) 898-1546
CITY:	SAN FERNANDO	STATE: CA	ZIP CODE:	91340
CAPACITY:	97	CENSUS: 32	DATE:	09/04/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Elia Caro		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility staff force fed resident resulting in multiple oral burn
Facility staff do not treat resident with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima made an unannounced subsequent visit to the facility to deliver finding for the above noted allegations at approximately 10:30AM. LPA Alvizar-Ettima met with Administrator and disclosed the purpose of the visit.

On 04/11/2024, Community Care Licensing Department (CCLD) received a complaint alleging that facility staff neglected and/or failed to provide an adequate level of care to the resident #1 (R1) resulting in R1 sustaining burns to their mouth due to being force fed hot soup.

The allegation was referred to Community Care Licensing Departments (CCLD) Investigation Bureau (IB) and the investigation was assigned to Senior Investigator (SI) Christine Ferris.

Initial visit was conducted on 04/12/2024 at approximately 10:00AM by LPA Antonia Alvizar-Ettima. During initial visit, at approximately 10:20AM, physical plant inspection was made to ensure that there are no

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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 31-AS-20240411103116

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOTHER GERTRUDE HOME	FACILITY NUMBER: 191290719
	VISIT DATE: 09/04/2024

NARRATIVE

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immediate health and safety hazard affecting residents. At 12:30PM LPA requested and received copies of R1’s ID/Emergency, Admission Agreement, Physician Report, Medication Administration Records, Unusual Incident Reports, Resident History Chart, Facility Menu, Resident and Staff roster.

Investigation was continued by SI Ferris. Interviews of the staff conducted by SI on 05/20/2024, revealed that staff denied the allegation. On 05/30/24 SI spoke with witnesses (W1) and (W2) who had knowledge about R1’s health care. W1 indicated that doctors were unable to establish the cause of R1’s injury and could not confirm they oral ulcer was a result of a thermal burn. Per witness (W2) R1’s statement regarding the incident was “nonsensical” and W2, had no worries or concerns with staff or the facility. On 06/03/2024, SI spoke with R1 and other residents. R1’s statements were inconsistent as to what occurred and other residents who R1 stated witnessed the incident denied seeing the incident.
A review of R1’s record conducted on 05/01/24 did not revealed any information to support the allegation.
Overall investigation did not provide sufficient information and/or evidence to substantiated neglect/lack of care. Therefore, based on observation, interviews and record review, the allegation is UNSUBSTANTIATED at this time.

Facility staff do not treat resident with dignity and respect.

It was alleged that staff get frustrated when residents gives them a hard time. During today's visit, at approximately 10:50AM LPA conducted physical plant tour, interview residents, administrator, and staff.

Interview with three (3) out of thirty-two (32) residents revealed that staff always treats them with dignity, respect and they do not have any concerns regarding this allegation. Residents reveal staff are never frustrated, staff are nice and help when they need it. Interview with Administrator and three (3) staff members reveal staff always treat residents with dignity and respect. Administrator indicated not receiving a complaint from residents, residents family members or other staff about staff not treating residents with dignity and respect. Administrator reveal that all residents, staff and visitors are treated with dignity, values and respect. Two (2) staff reveal residents are treated like family and they always respect the residents. LPA did not observe staff being frustrated at residents in care.

Based on information obtained through interviews and observation there is not enough sufficient evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No Deficiencies noted at time of visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC9099 (FAS) - (06/04)

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