195850091-8-3-2023-29-AS-KHEN-CUH23X-20230807170301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 08/02/2023
Date Signed: 08/03/2023 07:31:10 AM

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
07/26/2023 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20230726100620

FACILITY NAME:	PRESERVE AT WOODLAND HILLS, THE		FACILITY NUMBER:	195850091
ADMINISTRATOR:	TREVIN R WILLIS		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(747) 226-5834
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS:	DATE:	08/02/2023
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Trevin Willis		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff handled resident in a rough manner
Resident sustained a fall while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to deliver findings. LPA Ascencio met with Executive Director (ED) Trevin Willis at 1:35 p.m. Entrance interview conducted.

On 07/26/2023, the Department received a complaint alleging that staff handled resident in a rough manner and resident sustained a fall while in care. On 07/21/2023 via phone and on 07/28/2023, LPA Ascencio conducted an interview with ED Willis. Interview with ED Willis, at 1:25 p.m. revealed that there was an incident that happened on the night of July 20th, involving Resident #1 (R1), Staff #1 (S1), S2 and S3. Allegedly, around 8:30 p.m., R1 was in another resident’s room wandering around. S1 and S2 attempted to redirect R1 out of the resident’s room but had no success. According to S3, they observed S1 and S2 grab R1 violently and physically removed R1 from the room.

Continued on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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-20230726100620

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: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/02/2023

NARRATIVE

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ED Willis indicated that S1, S2 and S3 have been placed on administrative leave pending an internal investigation. ED Willis indicated that a skin assessment was conducted the following day and noted that the only bruising R1 presented was on R1’s forearms due to R1 bumping into walls or doors. Lastly, ED Willis stated that a De-Escalation Techniques training, Mandatory Reporter training and Elder Abuse training was going to be conducted with all staff in the near future. LPA Ascencio obtained copies of written statement from S1, S2, and S3, the Skin Monitoring Review conducted on 07/21/2023, R1’s Charting Notes and R1’s LIC 602 Physician’s Report.

According to R1’s LIC 602 Physician’s Report, R1 has a diagnosis of Alzheimer’s Disease/Dementia and 1 other diagnosis, no behavior conditions such as aggression or sundowning, and needs assistance with activities of daily living (ADL). A review of R1’s Charting Notes revealed R1 has had 2 fall, and 10 notes on aggression or agitation towards staff or other residents. Additionally, R1 is currently taking Quetiapine Furmate 25 mg at bedtime for agitation.

On 07/28/2023, LPA Ascencio conducted an interview with R1’s Family Member beginning at 1:45 p.m. Interview with R1’s Family Member revealed that the staff could not have treated R1 in a rough manner. Family member added that since moving into The Preserve in May 2023, they have had a wonderful time, with the best care staff experience. R1’s Family member stated they do not suspect that R1 was abused or mistreated by S1, S2 or any staff. Lastly, R1’s Family Member added that due to R1’s diagnosis of dementia, R1 has been presenting with more aggressive and agitative behaviors that are being monitored and controlled by medication. On 08/02/2023, starting at 2:10 p.m. interview with S1 was conducted revealing that R1 was in another resident’s room. When S1 and S2 attempted to redirect R1 out of the room, R1 began to get aggressive with the staff. S1 and S2 started to walk with R1 out of the room when suddenly R1 became “dead weight” and attempted to drop to the ground. S1 stated that both S1 and S2 were grabbing R1 underneath their arm preventing a fall, while R1 was trying to fall to the floor. S1 continued, at this moment, S3 came and observed the situation stated that we are handling R1 in a rough manner. That same day, interview with S2, starting at 2:20 p.m. confirmed what S1 stated and added that R1 did not fall to the ground but instead, was being held up by S1 and S2. Also, that same day, interview with S3, starting at 4:05 p.m. confirmed what S1 and S2 stated but added that S3 witnessed S1 and S2 swinging R1 around to get R1 out of another resident’s room, which was empty. S3 added that R1 was not agitated, both staff members could not provide a reason as to why R1 was removed from the room. Lastly S3 stated R1 did not fall to the ground but was being handled inappropriately. Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230726100620

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: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/02/2023

NARRATIVE

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Although a skin assessment was conducted on R1 the following day the alleged incident occurred, according to ED Willis, the skin assessment report indicated that the current bruises R1 had, was from R1 bumping into things in the facility. Additionally, ED Willis stated there was no indication that R1 was grabbed at the wrist or in any part of the arm as R1’s arm had no marks or bruising that suggest R1 was handled in a rough manner. Additionally, interviews with S1 and S2 indicated that they attempted to redirect R1 out of the room causing R1 to get upset and agitated, thus attempted to fall to the ground. S1 and S2 held onto R1 to prevent a fall and R1 causing self-harm by falling. At this moment S3 walked in and observed the situation accusing the staff members of abusing R1 by forcing resident out of the room. Interview with R1’s Family Member stated they do not suspect R1 was abused or mistreated and is enjoying their time and care the staff are providing R1. Thus, based on the evidence gathered there is insufficient evidence to prove that staff handled resident in a rough manner and resident sustained a fall while in care. Both allegations are deemed unsubstantiated at this time.

LPA Ascencio and ED Willis confirmed that further training is recommended on elder abuse and mandated reporting, in addition on interventions on dementia behaviors and documentation.

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

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC9099 (FAS) - (06/04)

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