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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 06/03/2022
Date Signed: 06/03/2022 06:17:11 PM

Substantiated


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
10/20/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20211020121650
FACILITY NAME:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR:WILLIAMS, CELESTEFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(818) 922-8980
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:60CENSUS: 13DATE:
06/03/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Eileen EsquivelTIME COMPLETED:
02:02 PM
ALLEGATION(S):
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Resident sustained multiple falls while in care.
Staff do not respond to resident's pendants in a timely manner.
Facility pendent system is in disrepair.
Residents room is not being cleaned regularly.
INVESTIGATION FINDINGS:
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On 06/03/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the above allegations. The LPA met with Executive Director, Eileen Esquivel at 10:30 a.m., and explained the reason for the visit.

On 10/26/2021, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial 10-day complaint investigation visit regarding the above allegations. LPA Urena met with the Executive Director (ED) Celeste Williams at 10:30 a.m., and explained the purpose of the visit. At 10:45 a.m., LPA Urena and Executive Director conducted a tour of the facility to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. From 11:05 a.m. to 2:30 p.m. the LPA conducted interviews with residents and staff. From 12:20 p.m. to 12:50 p.m., the LPA observed lunch time for residents. From 2:30 p.m. to 3:00 p.m., the LPA conducted records review.
Continues on LIC 9099 C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
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 7
Control Number 29-AS-20211020121650
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: 06/03/2022
NARRATIVE
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Resident sustained multiple falls while in care

On the allegation, ‘Resident sustained multiple falls while in care’. It is alleged that R1 has had five (5) falls since being admitted to the facility due to staff not responding to the pendant calls. To investigate this allegation, the LPA conducted interviews, and record review. On 10/26/2021, at 2:30 p.m., the LPA conducted record review and found that R1 had sustained four falls between the months of September, and October 2021. The in-house Incident Reports indicate that R1 ‘slipped’ from the bed four out of four times. The falls were described as R1 ‘slipping’ off the bed. The reports further indicate that R1 was assessed by the med tech, and no visible injuries were noted, and under the ‘Immediate Prevention of Re-occurrence’ section of the report, it states that R1 will be reminded to use the signal pendant when assistance is needed, and R1 will be checked on an hourly basis. On 10/25/2021 at 10:00 a.m., the LPA interviewed the Reporting Party (RP) in reference to the falls sustained by R1, and asked if R1 had sustained bruises, or injures due to the falls, and if R1 had been seen by a physician due to the falls? RP stated that R1 had not sustained bruises or any type of injury, nor had been seen by a physician. On 10/26/2021, at 2:00 p.m., the LPA interview the ED about the falls sustained by residents and the plan of action to ensure residents are safe. The ED stated that the beds have motion sensors that signal when residents get off the bed, and that the signal pendants work, but because the residents may suffer form memory loss, they may not remember to use the signal system, when assistance is needed. On 10/26/2021, at around 12:55 p.m., the LPA interview staff about the time frame to respond to the pendant calls? The staff stated that it usually takes five minutes from the time they receive the signal, but depending on the calls received at the same time, it may take longer than five minutes.



Based on the information gathered, interviews, and records review, the multiple falls of R1 while in care happened while resident was under care. Two of the falls documented in the in-house Incident Reports stated that the resident was attempting to get the pendant to call staff. Therefore, the allegation is deemed as SUBSTANTIATED at this time.

Continues on LIC 9099C...

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20211020121650
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: 06/03/2022
NARRATIVE
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Staff do not respond to resident's pendants in a timely manner.

On the allegation, ‘Staff do not respond to resident's pendants in a timely manner’. It is alleged that the resident will press their call pendent, but staff do not respond in a timely manner. It may take up to 20 minutes for a caregiver to respond. To investigate this allegation, the LPA conducted staff interviews. On 10/26/2021 at 1:15 p.m., the LPA interviewed staff about the respond time to calls from residents. The staff stated that the respond time should be within five minutes, however, depending on the needs of the residents, and the calls that may come in at the same time, it may take more than the five minutes. At the time of the visit, the census was seven (7). This is a one floor facility with capacity for 60 residents, and has 50 rooms numbered from 101 to 150. The current residents reside in rooms far from each other (100’s, 120’s, 130’s 140’s). On 10/26/2021, the LPA observed one caregiver, and one med tech, as the primary care staff. Staff reported that they are performing duties not included in their job description. On 10/26/2021 at 2:00 p.m., the LPA interviewed the ED about staffing, and response time to the pendant calls. The ED stated that hired staff are assisting with different duties due to the low census at the facility. As the resident numbers increase, more staff will be brought aboard. The response time to the residents’ calls should not be more than 10 minutes, and that staff communicate with radios to prioritize the calls, and needs of the residents. The ED stated that the HSD and including the ED assist with calls.

Based on the observation, and interviews, the insufficient staff (in numbers) is preventing staff from responding to residents’ pendants in a timely manner. Therefore, this allegation is deemed SUBSTANTIATED at this time.

Facility pendant system is in disrepair.

On the allegation, ‘Facility pendent systems is in disrepair’. It is alleged that the staff stated that the "security system" for the pendent to get to a caretaker's pager is broken; so, the system sometimes works, and sometimes it does not.

Continues on LIC 9099 C...

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20211020121650
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: 06/03/2022
NARRATIVE
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To investigate this allegation the LPA conducted interviews, and record review. On 10/26/2021 at 2:00p.m., the LPA interviewed the ED, and asked about the pendant call system. The ED stated that the system is a call system in the residents’ rooms. The system is called the Vigil Remote system, and it is activated by residents’ movement. There is also a pull cord system in the bathroom. The motion sensor system sends a signal when a resident is moving about in their room, and the signal goes to a pager carried by caregivers, and the Health Services Director (HSD). Staff communicate with each other via a radio to respond to the calls. The call is then deactivated when the caregiver responds to the resident’s room by pressing a button outside the room. The ED stated that the system gets overloaded when the caregivers forget to deactivate the system. The LPA asked the ED to show how the system is monitored, who monitors the system, and the location of the system. The ED and the HSD showed that the system monitor is located in a monitor room, and the operation of the system is accessed through the computer in the Health Services Director office. However, on the day of the visit on 10/26/2021 at around 11:05 a.m., neither the ED nor the HSD could access the system through the HSD computer. Consequently, the LPA could not assess the functions of the pull cord system/motion sensor, because it was not functional. On 10/26/2021 at 1:15 p.m., the LPA interviewed staff, and staff stated that they respond to the calls when they receive calls on the pager, and within five minutes if it is possible, and depending on the calls coming in at the same time. However, they don’t know if the system malfunctions. On 10/25/2021 at 10:00 a.m., the LPA interviewed the RP, and they stated that they have communicated with the Vice President of Operations for the corporation, and was told that they are working on it (pendant system).

Based on the observations, information gathered, and interviews, the facility pendent system sometimes works, and sometimes does not. Therefore, the allegation is deemed SUBSTANTIATED at this time.

Residents’ room is not being cleaned regularly.

On the allegation, ‘Residents’ room is not being cleaned regularly’. It is alleged that during a visit it was observed that the resident’s room had ‘dust balls’ all over the floor, the toilet and bathroom were dirty, and it appeared that the room had not been cleaned in a while. The room is supposed to be cleaned once a week.

Continues on LIC 9099 C...

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20211020121650
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: 06/03/2022
NARRATIVE
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To investigate this allegation, the LPA conducted a tour of the facility rooms, staff interviews, and record reviewed. On 10/26/2021 at 10:45 a.m., the LPA and the ED conducted a brief tour of the residents’ rooms residing at the time of the visit. On this day the census was six (6). The LPA and the ED toured six out of six bedrooms. Six out of six bedrooms, and bathrooms appeared to be in clean condition, with adequate lighting, furnishings, and linens. During the tour, the LPA interviewed the ED about the housekeeping services for the residents, and the ED stated that at the moment, the facility did not have housekeeping personnel. The housekeeping staff quit, and that the staff is presently hired, including the ED were taking turns doing cleaning duties. The LPA asked the ED to see a schedule of the housekeeping duties. The ED stated that there was not a schedule, and that everyone pitched in as needed. On 10/26/2021 the LPA interviewed staff at approximately 2:00 p.m. about housekeeping duties. Staff stated that there is no housekeeping staff, and that current staff assist with cleaning duties, although it is not part of their job description, staff added that the rooms are filthy.

Based on the information gathered and interviews conducted, housekeeping services are not being met due to the facility not having hired staff to perform housekeeping duties, consequently the residents’ rooms are not being cleaned regularly. Therefore, the allegation is deemed SUBSTANTIATED at this time.

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



Exit interview was conducted with the Licensee's representative. The Report and Appeal Rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20211020121650
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: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2022
Section Cited
CCR
87468.2(a)(4)
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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:
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The ED will submit an Operational Procedure that describes the steps taken to ensure staff monitor the Vigil system and respond within the expected 5 minutes time frame to pendant calls. Additiionally the ED will send a sign in sheet and agenda for staff refersher training.
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Based on the investigation, and interviews, the licensee did not comply with the section cited above, as residents were not properly supervised, due to insufficient staff in numbers, which led to falls due to the delayed assistance, which poses an immediate personal rights risk to residents in care.
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Type A
06/30/2022
Section Cited
CCR
87468.2(a)(4)
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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:
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The ED will submit an Operational Procedure that describes the steps taken to ensure staff respond to pendant calls within 5 minutes and that enoiugh staff is available to ensure care and supervision of all residents currently residing at the faciltiy.
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Based on the investigation, and interviews, the licensee did not comply with the section cited above, as staff did not respond to residents pendant signal, due to insufficient staff in numbers, which led to delayed assistance, and poses an immediate personal rights risk to residents in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20211020121650
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: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2022
Section Cited
CCR
87303(i)(1)(B)
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87303(i)(1)(B) Signal System- (i)Facilities shall have signal systems (1)All facilities licensed for 16 or more… shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidenced by:
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The ED showed the LPA the system is up and running, and functionng propertly. The deficiency has been cleared as of today's visit 6/3/2022.
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Based on the investigation, and interviews, the licensee did not comply with the section cited above, as the signal system is not functioning properly, which poses an immediate personal rights risk to residents in care.
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Type A
06/30/2022
Section Cited
CCR
87303(a)
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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:
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The ED provided proof of housekeeping staff being hired as of 05/18/2022. This deficiency has been claered as of today's visit on 6/3/2022.
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Based on the investigation, and interviews, the licensee did not comply with the section cited above, as a housekeeping staff was not hired at the time of the visit, which poses an immediate health and safety risk to residents in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
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