195850091-8-13-2024-29-AS-KHEN-D9FLMS-20240925085313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:11:11 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
07/23/2024 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20240723133024

FACILITY NAME:	PRESERVE AT WOODLAND HILLS, THE		FACILITY NUMBER:	195850091
ADMINISTRATOR:	MICHAEL OWENS		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(747) 226-5834
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS: 40	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Trevin Willis		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff admitted a resident beyond their level of care.
Facility staff not ensuring resident's diabetic needs are met.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Emily Peraldi and Angela Barutyan conducted an unannounced subsequent visit to this facility to deliver findings. At 9:45 a.m., the LPAs met with staff and explained the reason for the visit. At 10:03 a.m., Executive Director (ED) Trevin Willis arrived at the facility.

During the initial visit conducted on 07/24/2024, between 1:00 p.m. and 4:05 p.m., LPA Peraldi met with Resident Care Coordinator (RCC) Ana Gutierrez and conducted a physical plant tour and requested pertinent documents. The LPA also conducted interviews with seven (7) staff and two (2) residents. During today’s visit, the LPAs conducted a brief physical plant tour and reviewed resident records.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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 29-AS-20240723133024

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/13/2024

NARRATIVE

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Regarding the allegations: 1.) Facility staff admitted a resident beyond their level of care. 2.) Facility staff not ensuring resident's diabetic needs are met. On 07/23/2024, the Department received a complaint alleging that Resident #1 (R1) who is diabetic and requires finger prick testing twice a day to test blood sugar was admitted to the facility. The complainant is alleging that R1 does not have the capacity to perform a self-finger prick test and the facility does not have an appropriate skilled professional to perform the test, hence not meeting R1’s diabetic needs. Per record review, R1 was discharged from Kaiser Permanente Hospital and admitted to the facility on 06/08/2024. Per R1’s hospital records and discharge medication list dated 06/08/2024, R1 was to continue performing OneTouch Verio test strips with the following instructions “Check your blood sugar 2 times a day every morning before breakfast and every evening before dinner.” Per R1’s physician report dated 06/07/2024, R1’s primary diagnosis is noted as Dementia and secondary diagnosis as Diabetes. R1’s physician report also indicated that R1 is not “Able to perform own glucose testing.” During R1’s stay at the facility, R1’s blood sugar was not being tested daily. On 07/23/2024, the previous management team quit and did not leave clear instructions regarding R1’s diabetic needs to remaining staff. Interviews with staff revealed that R1 was not getting their blood sugar tested and instead, previous management was attempting to contact R1’s physician to get the blood sugar test discontinued. Additionally, the facility does not have a skilled professional to perform R1’s blood sugar test. The facility’s current ED, Trevin Willis, worked with R1’s family to find an appropriate licensed facility that can perform R1’s blood sugar test. On 08/08/2024, R1 was moved out of the facility. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations of “Facility staff admitted a resident beyond their level of care” and “Facility staff not ensuring resident's diabetic needs are met” are deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240723133024

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/14/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	On 08/08/2024, R1 was moved out of the facility due to the facility not being able to meet R1 diabetic needs. The Administrator will submit a statement of understanding regarding the above regulation by due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the above cited section, as facility accepted R1, who could not perform own glucose testing and facility did not have skilled professional to perform the glucose test which posed an immediate health risk to residents in care.	8 9 10 11 12 13 14	Additionally, Administrator stated that he will submit a plan on how the facility will ensure residents' basic services will be met by due date.
Type A 08/14/2024 Section Cited CCR 87628(a)	1 2 3 4 5 6 7	87628(a) Diabetes (a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing…, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	On 08/08/2024, R1 was moved out of the facility due to the facility not being able to meet R1 diabetic needs. The Administrator will a statement of understanding regarding the above regulation by due date.
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee did not comply with the section cited above as R1 could not perform own glucose testing and facility did not have skilled professional to perform the glucose test which posed an immediate health risk to resident in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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