195850091-3-16-2022-29-AS-JAPL-CCMSFY-20220318135108

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 03/16/2022
Date Signed: 03/16/2022 04:07:27 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
01/03/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220103170508

FACILITY NAME:	PRESERVE AT WOODLAND HILLS, THE		FACILITY NUMBER:	195850091
ADMINISTRATOR:	EILEEN ESQUIVEL		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(818) 922-8980
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS:	DATE:	03/16/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Michael Owens, Resident Care Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff failed to supervise resident, resulting in resident AWOL

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for subsequent complaint visit. The LPA met with Resident Care Director Michael Owens and explained the reason for the visit. During the initial visit conducted on 1/12/2022, LPA Zabel Chochian conducted a physical plant tour between 3:45pm-4:15pm and observed one (1) out of three (3) delayed egress doors inoperable.

During a subsequent visit conducted on 2/2/22 the LPA conducted a facility tour at 9:34 a.m., interviewed staff at 10:07 a.m., 11:16 am., 11:48 a.m. 12:19 p.m. and 12:45 p.m., reviewed documents at 10:20 a.m., and interviewed resident at 12:10 p.m. In addition, the LPA conducted staff interviews on 2/24/22 at 4:38 p.m. and 2/26/22 at 11:08 a.m. During today’s visit the LPA conducted a physical plant tour at 10:20 a.m.

Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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 3

Control Number 29-AS-20220103170508

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: 03/16/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation #1: Facility staff failed to supervise resident, resulting in resident AWOL. It is alleged that on 12/31/2021 that R1 eloped from the facility. According to the information obtained, the day R1 eloped from the facility, R1 was found at least half (1/2) a mile from the facility. The investigation revealed that prior to the incident, R1 was believed to be in their room. R1 wandered out of their room to the far-left exit door located at the back of the facility. Whereas this rear exit door is a delayed egress door, it was inoperable at the time. Care staff did not notice that R1 left the building as they were attending to other residents.

After doing resident rounds, staff realized that R1 was not in the facility. Two (2) staff left the facility to find R1. Staff confirmed that they found R1 approximately fifty (50) minutes later and R1 was safely returned to the facility. In response to the incident, staff fixed the delayed egress door, installed cameras and additional alarms.

However, on 2/23/22, staff reported that R1 once again eloped from the facility. According to the information obtained, R1 eloped from the facility through the front doors. The investigation revealed that prior to the incident, R1 was in the dining room along with eight (8) other residents and three (3) care staff. R1 wandered out of the dining room and left through the front door near the reception area which is not equipped with delayed egress. Staff that was present in the dining room did not notice that R1 had left the building. Staff had received notifications on their phone alerting them that a door had been opened and care staff failed to respond to the notification immediately. One (1) staff left the facility to find R1. Staff confirmed that they found R1 approximately one (1) block away and was safely returned to the facility. In response to the incident, staff installed an additional alarm to the front door and conducted an in service elopement training and drills.
Therefore, based on information obtained and interviews conducted, the allegation lack of supervision resulted in resident eloping, is SUBSTANTIATED at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20220103170508

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/18/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Per the visit the facility conducted an in-service training on 3/9/22 and conducted elopement drills on 2/25/22, 2/28/22, 3/2/22, 3/10/22 and 3/13/22. The facility has committed to conducting elopement training on a monthly basis and will send sign in sheet no later than 3/18/22. The LPA obtained documents from the previous elopement drills.
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited above, as residents were not properly supervised which led to an elopement, which poses an immediate personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 03/16/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by:	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited above, as one (1) out of three (3) delayed egress doors were inoperable, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Per the visit the facility fixed the delayed egress. The licensee agreed to provide proof of date of service to CCL no later than 3/18/22.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3