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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 07/13/2022
Date Signed: 07/13/2022 12:08:03 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
12/03/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211203112208
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: 18DATE:
07/13/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Eileen EsquivelTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident sustained multiple injuries while in care
Insufficient staffing to meet resident needs
Staff did not ensure resident was adequately fed and hydrated
Staff inadequately trained
Staff failed to reposition resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Ashley Smith and Elsie Campos arrived unannounced for a subsequent visit. The LPAs met with Executive Director Eileen Esquivel and explained the reason for the visit.

On 12/10/2021, LPAs Ashley Smith and Elsie Campos conducted a physical plant tour at 1:55 p.m., conducted a file review at 2:59 p.m. and interviewed staff at 2:10 p.m. On 4/16/2022, the LPAs conducted a tour at 1:20 p.m., conducted a file review at 11:00 a.m. and interviewed staff at 11:50 a.m., 12:23 p.m., 1:00 p.m., 3:20 p.m., and 3:49 p.m. On 5/10/2022, the LPA conducted a medication audit from 2:15 p.m. – 3:30 p.m., and audited files from 3:30 p.m. – 4:00 p.m. In addition, the LPA reviewed the Medication Administration Record (MAR) for Resident #1 (R1). Additional interviews were conducted with former and current staff on 6/17/2022 at 1:47 p.m. and 5:28 p.m. In addition, the LPA subpoenaed home health and hospital records and reviewed documents pertinent to the case.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
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 6
Control Number 29-AS-20211203112208
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: 07/13/2022
NARRATIVE
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Regarding the allegations: Resident sustained multiple injuries while in care
It was alleged that upon being admitted to the hospital, R1 was admitted with pressure injuries. R1’s physician’s report dated 11/5/2021 and R1’s service plan (date unknown) did not indicate that R1 had any wounds or injuries prior to being admitted to the facility. Facility records noted that R1 was receiving home health services while residing at the facility; however, records indicated that R1 was discharged from home health services on 11/29/2021 due to lack of funding due to insurance changes. Home health records indicated that on 11/16/2021, R1 was found with a pressure injury on the heel and possibly one on the coccyx. In addition, whereas staff claim that residents are regularly repositioned as needed, there were no records or evidence to indicate whether R1 was regularly repositioned. Upon being admitted to the hospital on 12/2/2021, R1 was found with the following pressure injuries: unstageable pressure injury on the left plantar heel, stage 3 pressure injury on the left buttocks, right ear lesion, and right heel blanchable. There was no evidence of an exception to retain R1 on file, nor was R1 receiving hospice services.

Based on the information obtained, there is sufficient evidence to support the claim that R1 sustained multiple injuries while in care. This allegation is deemed Substantiated at this time.

Regarding the allegation: Insufficient staffing


It was alleged that at the time the complaint was received, the facility had insufficient staffing due to staff being fired and/or quitting. As a result, resident care needs were let un-met. Staff interviews revealed that the licensee indeed let go of staff due to the challenges and complaints that were received from resident’s family members. Staff also claimed that management staff would step in and provide care for the residents when there were an insufficient number of caregivers or medication technicians on the floor. Yet interviews with former and current staff confirmed that there often are a lot of call-offs and admitted that resident needs could not be met. Staff confirmed that due to lack of sufficient staffing, they have not followed the care plan for Resident #4 and Resident #5 (R4, R5) both whom require two-person assist for transfers. Staff also noted that they had worked alone in the facility due to insufficient staffing. In addition, a facility file review revealed that on 12/31/2021 and 2/23/2022, Resident #6 (R6) eloped from the facility while in care due to lack of care and supervision.

Based on the information obtained, there is sufficient evidence to support the claim of insufficient staffing. This allegation is deemed Substantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20211203112208
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: 07/13/2022
NARRATIVE
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Regarding the allegation: Staff did not ensure resident was adequately fed and hydrated
It was alleged that upon admission to the hospital on 12/2/2021, R1 was severely dehydrated and malnourished. A review of documents indicated that R1 required assistance with feeding, as they could not feed themselves. In addition, a medication review revealed that as of 11/17/2021, R1 had a prescription to receive Ensure twice daily. However, a review of notes and staff interviews noted that R1 had not been eating for ‘several days’, reason unknown. Staff admitted that it was challenging to ensure that R1 was fed and hydrated, despite the different methods they tried. Staff claimed that R1 had stopped taking food to the mouth and staff admitted that R1 needed a higher level of care. Whereas there were no weight records to indicate R1’s weight upon admission to the facility, R1’s weight upon hospitalization on 12/2/2021 was 105 pounds. Upon discharge from the hospital, R1’s weight on 12/8/2021 was 111 pounds. Records indicated that R1 had returned to baseline and was eating while residing at the hospital. If staff felt that they were unable to ensure that R1 was adequately fed and hydrated, the facility was then unable to meet the resident need and R1 subsequently required a higher level of care. There were no records to confirm whether staff contacted R1’s physician regarding R1’s failure to thrive, and furthermore, it was the R1’s responsible party whom took R1 to the hospital.

Based on the information obtained, there is sufficient evidence to support the claim that staff did not ensure resident was adequately fed and hydrated. This allegation is deemed Substantiated at this time.

Regarding the allegation: Staff inadequately trained
During the initial visit conducted on 12/10/2021, twelve staff files were audited to identify whether staff completed the minimum forty (40) hours of initial training. Out of the twelve files audited, four out of twelve staff had completed the minimum hours of initial training. However, three out of twelve files (Staff #2, Staff #4, Staff #5) had insufficient training hours completed, and five out of twelve staff (Staff #6, Staff #7, Staff #8, Staff #9, Staff #10) did not have a transcript or training hours available at the time of the visit. Interviews confirmed that the training transcripts were the only available documents to confirm completed training hours. Staff interviews confirmed that at the time of the visit, the Executive Director was tasked with updating staff and resident files, and understood that many staff were deficient in their training hours. Based on the information obtained through the course of the investigation, there is sufficient evidence to support the claim that staff were inadequately trained. This allegation is deemed Substantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20211203112208
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: 07/13/2022
NARRATIVE
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Regarding the allegation: Staff failed to reposition the resident
It was alleged that staff failed to reposition the resident, which aided in the development of pressure injuries. Records review indicated that R1 was either bed-bound or in their wheelchair. Records also noted that R1 was unable to reposition themselves. Interviews confirmed that whereas staff do not keep repositioning logs, former and current staff claimed that they reposition residents every two hours. Unfortunately, were no facility records to show staff had a schedule to frequently check R1 for incontinence care or repositioning. In addition, staff stated that most residents are out of bed and are congregating in common spaces. Consequently, interviews with former staff and record review confirmed that R1 had developed a pressure injury on the heels and that they had provided wound care. Home health records indicated that on 11/16/2021, R1 was found with a pressure injury on the heel and the coccyx.. Upon being admitted to the hospital on 12/2/2021, R1 was found with the following pressure injuries: unstageable pressure injury on the left plantar heel, stage 3 pressure injury on the left buttocks, right ear lesion, and right heel blanchable. Hospital records review indicated that R1 required maximum assistance due to poor mobility, and noted that R1 was cooperative with care and turning. Based on the information obtained, there is sufficient evidence to support the claim that staff failed to reposition the resident, which aided in the development of pressure injuries. This allegation is deemed Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. Exit interview conducted. A copy of the report was issue, along with appeal rights.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20211203112208
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: 07/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2022
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including... those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Schedule a training regarding Prohibited Health Conditions and Pressure Injuries. Verification of scheduled training with the trainers credentials will need to be submitted by 7/15/2022 and completion of training must be submitted no later than 7/29/2022.
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Based on the investigation, the licensee did not comply with the section cited above, as R1 was retained at this facility with unstageable pressure injuries, which poses an immediate health and safety risk to residents in care.
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An immediate civil penalty of $500 is assessed.
Type A
07/15/2022
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit a Staffing Plan to CCL and updated schedule by 7/15/2022.
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Based on interviews and record review, licensee failed to ensure that the facility had an adequate number of staff to meet the residents needs, 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: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20211203112208
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: 07/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2022
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities . 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 is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit a Plan of Action, indicating how the facility plans to maintain voluntary compliance for R4, R5, R6. Submit Plan by 7/15/2022.
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Based on the investigation, the licensee did not comply with the section cited above regarding resident care needs and services for R1, R4, R5, and R6 which poses an immediate health and safety risk to residents in care.
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2. Review the care plans for the residents that are currently in the facility. Identify any changes that are needed, and update plans accordingly. Inform the CCL when this is completed, but no later than 8/5/2022.
Type B
07/29/2022
Section Cited
HSC
1569.625(b)(1)
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1569.625( b)(1) Staff training; legislative findings. Staff members...who assist residents with personal activities of daily living to receive training. This training shall consist of 40 hours of training ….and shall be completed within the first four weeks of employment.
This requirement is not met as evidenced by:
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The Administrator agreed to the following:
1. Submit a Plan of Action, detailing how the facility will maintain compliance with the regulation.
2. Audit staff files and ensure all staff have the forty (40) hours of initial training. Submit completion by 7/29/2022
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Based on the investigation, the licensee did not comply with the section cited above in eight out of twelve staff, which poses a potential 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: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6