<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850162
Report Date: 01/20/2022
Date Signed: 01/20/2022 04:29:45 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
08/09/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20210809092937
FACILITY NAME:COMFORT ELDERLY CAREFACILITY NUMBER:
195850162
ADMINISTRATOR:MAKHTESYAN, DIANAFACILITY TYPE:
740
ADDRESS:22806 CALIFA STREETTELEPHONE:
(818) 602-1622
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
01/20/2022
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Michael Angelo Cezar N. TolentinoTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained pressure injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/20/2022, at 3:45 p.m., Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to issue the final report regarding an investigation into the allegation, “Resident sustained pressure injuries while in care”. The LPA was greeted by staff. Staff called administrator Naira Paroyan to inform her of the LPA visit. Staff reported to the LPA that the administartor was on the phone and would call the LPA back.The adminitrator called at 4:10 p.m. and the LPA explained the reason for the visit. Additionally via cell adminstrator stated that she was allowing staff Michael Angelo Cezar N. Tolentino to sign off on the report .

On 8/09/2021, Licensing Program Analyst (LPA) Sandra Urena initiated an unannounced initial 10-day complaint investigation visit to address the above noted allegation. At 1:15 p.m., the LPA arrived at the facility, met with the caregiver, and explained the reason for the visit. The caregiver called the administrator, Naira Paroyan, to inform them of the visit. The administrator stated that they could not make it to the facility due to being at their other employment, which is unrelated to the facility.
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: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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-20210809092937
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 01/20/2022
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
The LPA requested to see the file for Resident #1 (R1), the staff work schedule, and the roster for the staff; however, the staff schedule and roster were not available at facility. The administrator stated that the staff schedule and roster would be sent via email before the end of the day. The LPA asked the administrator if R1 was receiving Home Health Care or Hospice Care services while residing at the facility and the administrator confirmed that the resident was not receiving those services.

At 1:30 p.m., the LPA requested the following records for review: Admission Agreement, Appraisal/Needs and Services Plan (LIC 625), Resident Appraisal (LIC 603A), Physicians Report (LIC 602A), copy of the Unusual Incident/Injury Report (LIC 624), Preplacement Appraisal Information (LIC 603), and hospital discharge paperwork for R1 prior to being placed at Comfort Elderly Care facility.

On 8/09/2021, the Woodland Hills North Adult and Senior Care Regional Office referred this case to the Community Care Licensing (CCL) Investigations Branch (IB). On 8/09/2021, IB Investigator Brian Slatic, Badge # 216, was assigned to investigate the allegation(s).

Regarding the allegation, ‘Resident sustained pressure injuries while in care’, on 5/17/2021, Special Investigator Assistant (SIA), V. Padilla sent a subpoena to one hospital requesting the medical records for R1. On 8/27/2021, IB Investigator Slatic received a copy of the medical records for R1, and on 9/13/2021, IB Investigator Slatic reviewed the medical records. Additionally, on 10/25/2021, SIA V. Padilla received the medical records from a second hospital for R1, and IB investigator Slatic reviewed the records on 10/25/2021. The following is a summary of the records review.



The medical records review revealed that R1 had been living alone and was found disoriented, and unable to care for themselves. R1 was originally taken to one hospital, then transferred to another hospital. When it was time to discharge the resident, the discharge planner then contacted Comfort Elderly Care (CEC) on 7/18/2021, and CEC agreed to accept R1. On 7/18/2021, R1 was transferred to and admitted at CEC. At the time of the transfer to the CEC facility, R1’s hospital physician’s report dated 07/18/2021 does not document anything about bruises, sores or any history of skin breakdown. No pressure injuries, wounds, redness, or skin irritations were noted in the report.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 29-AS-20210809092937
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 01/20/2022
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
On 8/31/2021, IB Investigator Slatic received and reviewed the CEC facility records. The following is a summary of the records review. Facility records indicate that R1 had two preplacement appraisals in R1’s file. One preplacement appraisal dated 7/18/2021 (signed by an unknown person), states bruises and redness are visible all over the skin, along with a bandage on the left elbow, and sores on the lower extremities. It also states R1 is severely dehydrated and appears malnourished with rib cage visible. However, a second unsigned preplacement appraisal dated 7/18/2021 and 7/19/2021 states only that R1 seems to be in relatively poor health, with confusion, disorientation and altered level of consciousness. The R1’s second appraisal does not mention anything about bruising, sores or redness.

On 10/28/2021, IB Investigator, B. Slatic interviewed the responsible persons for R1. The responsible persons stated that they visited R1 a few times between 7/18/2021 and 7/27/2021, and during these visits R1 was always lying in bed, fully clothed, and wearing socks. As a result, the responsible persons never had the opportunity to observe R1’s skin condition and did not have a reason to personally check the covered areas of R1’s body. When the responsible persons would ask R1 if anything was hurting, R1 would not specifically complain about pain or discomfort on any particular region of the body, but R1 would just “moan and groan”. Responsible persons stated that they were not aware of any serious skin integrity issues, wounds or sores. Furthermore, none of the staff made the responsible persons aware, nor did they emphasized the need to contact the hospital for home health care services.


On 11/23/2021, IB Investigator, B. Slatic conducted a second interview with the responsible persons for R1. This interview was to confirm information found on a facility incident report dated 7/19/2021, and to discuss the preplacement appraisals for R1. The report stated that the POA was informed about the poor condition of R1 upon arrival at the CEC facility: dehydrated, bruising, and sores in parts of R1’s body. The POA denied that anyone from the facility had informed the POA about the condition of R1. The responsible persons denied that R1 arrived at the facility with bruises, wounds and dehydration. Additionally, the report states that it was discussed with the POA about sending R1 back to the hospital or placing R1 in palliative care. The POA denies such conversation took place. In regard to the preplacement appraisals, the POA stated that the pre-placements appraisals were never discussed for input nor for signatures, and the only document the POA signed was the admission agreement.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210809092937
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 01/20/2022
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
IB Investigator, B. Slatic conducted staff interviews from 11/24/2021 to 12/18/2021. Three (3) staff were interviewed and they noted that R1 was “ok”, on the days they were working. R1 was in bed the entire time and did not get up or was walked. R1 was not provided a formal bath; and R1 was fed, provided incontinent care, all while R1 was lying in bed. R1 had difficulty swallowing and as a result, did not eat very much. One staff did not observe any wounds, sores or skin integrity issues; however, one of the other staff stated that they observed redden skin and areas with a rash, so staff would provide ointment in the areas with the rash. Another revealed that the administrator claimed that R1 had skin integrity issues at the time of admission to the facility, and that the administrator contacted the hospital. However, after review of the hospital records, there is no evidence that the administrator requested any type of service for R1; and, none were provided. The facility did not pursue any other care options, allowing R1’s condition to worsen. In addition, since Home Health was not ordered to provide care to R1 for the pressure injuries, the pressure injuries were not treated by an appropriately skilled professional, as required.

R1 had been admitted to the facility on 7/18/21. On 7/27/2021 at approximately 11:14 a.m., R1 arrived at the hospital by ambulance from the CEC facility. R1 was initially transported to the hospital due to AMS (altered mental status), and dyspnea (labored breathing). The hospital’s clinical evaluation noted: Sepsis, AKI (kidneys), dementia, AMS, elevated troponin (indicates possible heart attack), hypoxia, and respiratory failure. Sepsis was confirmed and dehydration, along with severe protein calorie malnutrition was also noted. The physical exam revealed that R1 was a “cachectic (general physical wasting), chronically-ill appearing, ill-kempt” patient. Photos of the pressure injuries were taken on 7/27/2021, and they were staged as a Stage 2 on the coccyx, with suspected deep tissue injury (DTI). Additional wound photos were taken of the left foot with DTI, heel (not rated), right shin (unstageable), left leg (DTI), left hand (DTI), and right foot (not rated). A wound culture was performed on 7/28/2021 on several wounds on the sacral coccygeal area. This was thought to be the source of the infection. So, at minimum, R1 was admitted to the hospital with one stage 2 pressure injury on the coccyx, an unstageable pressure injury of the right shin and several deep tissue injuries. Although a wound consultation was ordered, it does not appear that it was completed while R1 was in this hospital.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210809092937
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 01/20/2022
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
Based on the medical records review and interviews, the investigation revealed that the hospital did not note any wounds or skin care issues when discharging the resident to the facility on 7/18/21. One staff did not notice any pressure injuries, while two other staff did note skin integrity issues and/or wounds/rashes. Care for the pressure injuries was not provided by an appropriately skilled professional. On 7/27/2021, R1 was admitted to the hospital with one stage 2 pressure injury on the coccyx, an unstageable pressure injury of the right shin, several deep tissue injuries and several other wounds that were not staged. Therefore, the allegation that ‘Resident sustained pressure injuries’ while in care is deemed Substantiated at this time.

The following deficiencies are observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. An immediate $500 civil penalty is being assessed today. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Furthermore, R1 was admitted to the facility with a pre-admission appraisal, which was developed without the involvement and approval from the responsible persons for R1, which will be addressed on a case management visit.

Citations were issued. Exit interview conducted. Today's reports, and appeal rights were reviewed with staff Michael Angelo Cezar N. Tolentino. Report and Appeal Rights were issued via email to Administrator Naira Paroyan.

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

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20210809092937
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2022
Section Cited
CCR
87615(a)(1)
1
2
3
4
5
6
7

87615 Prohibited Health Condition (a) Persons who require health services for or have a health condition including, ..., 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:
1
2
3
4
5
6
7
Licensee agrees to provide training to staff on how to recognize the progression of pressure injuries, provide a plan of action on steps, which would include: frequent assessment by the administrator of the resident’s skin condition, staff trained to report any skin changes to the administrator,
8
9
10
11
12
13
14

Based on interviews and record reviews, the licensee did not comply with the section cited above, as R1 developed, at minimum, one (1) unstageable pressure injury, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
notifying the resident’s physician of the pressure injury, ensuring that treatment is provided by an appropriately skill professional, immediately seek a higher level of care if the wound has exceeded a stage 2 pressure injury.
Type A
01/28/2022
Section Cited
CCR
87631(a)(3)(A)(B
1
2
3
4
5
6
7

Except as specified in Section 87611(a), Healing Wounds the licensee shall be permitted to accept ...: (3) Residents with a... (A) The ...receive care for the pressure injury from a physician or an appropriately skilled professional. (B) All aspects of care... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to provide training to staff on how to recognize the progression of pressure injuries, provide a plan of action on steps, which would include: frequent assessment by the administrator of the resident’s skin condition, staff trained to report any skin changes to the administrator,
8
9
10
11
12
13
14


Based on interviews and record reviews, the licensee did not comply with the section cited above, as R1 developed a Stage 2 pressure injury...an unstageable pressure injury... un-staged pressure injuries, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
notifying the resident’s physician of the pressure injury, ensuring that treatment is provided by an appropriately skill professional, immediately seek a higher level of care if the wound has exceeded a stage 2 pressure injury
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: 01/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6