197601221-9-7-2022-31-AS-RRAZ-CJ7JRH-20220912071643

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197601221
Report Date: 09/07/2022
Date Signed: 09/07/2022 05:11:34 PM

Unsubstantiated

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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2021 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210309100124

FACILITY NAME:	MARBLE TERRACE		FACILITY NUMBER:	197601221
ADMINISTRATOR:	GODLEWSKA, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	5811 DONNA AVE.		TELEPHONE:	(818) 708-2327
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 6	DATE:	09/07/2022
		UNANNOUNCED	TIME BEGAN:	04:45 PM
MET WITH:	Bowena Kozbial		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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1. Resident sustained unexplained bruising
2. Resident sustained pressure injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness met with Co-Administrator Bozena Kozbial to deliver the final finding of the allegations mentioned above. The following was determined:

Allegation # 1: Resident sustained unexplained bruising: Concerns were expressed that resident # 1(R1) sustained unexplained bruising while in care at the facility. On March 10, 2021; May 25, 2021; March 11, 2022; and March 16, 2022, from various times from 8am to 4pm, LPA conducted interviews with the complainant, staff, and R1’s family member. LPA also requested resident and medical documents pertaining to R1. Records and information were obtained and reviewed. Based on interviews from staff and R1’s family member, R1 was on and off hospice for over (2) years. In February 2021, R1’s health began to deteriorate, and was R1 non-ambulatory and bedridden. R1 was provided the appropriate and proper level of care, but due to R1’s history of lower extremities edema and sensitive skin, R1 tended to bruise easily. R1 was not able to be interviewed due to R1 passing away on May 02, 2021. Medical records confirm a history of skin related issues and that R1 was completely dependent on staff for ADL’s (activities of daily living) which could explain

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

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 31-AS-20210309100124

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARBLE TERRACE	FACILITY NUMBER: 197601221
	VISIT DATE: 09/07/2022

NARRATIVE

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any bruises. Also, interviews revealed that no one witnessed R1 being mishandled by staff and family and others were happy with the care provided by the facility. It was also revealed to the LPA that there were concerns with services provided to R1 without the permission of the Power of Attorney (POA) who questioned why R1 was assessed without their knowledge. Therefore, based on interviews, resident and medical records, pertaining to R1, the allegation is UNSUBSTANTIATED.

Allegation # 2: Resident sustained pressure injuries while in care: Concerns were expressed that resident # 1 (R1) sustained pressure injuries while in care. On March 10, 2021; May 25, 2021; March 11, 2022; and March 16, 2022, from various times, 8am to 4pm, LPA conducted interviews with the complainant, staff, and R1’s family member. LPA also requested and reviewed resident and medical documents pertaining to R1. Records and information were obtained and revealed that R1 was on and off hospice for over (2) years. In February 2021, R1’s health began to deteriorate, and according to information obtained by staff, R1 was non-ambulatory and bedridden, and in February 2021, staff observed R1 developing a pressure injury on the coccyx area. Staff immediately contacted the primary physician, who then ordered home health to treat the wound. R1’s insurance, Kaiser Hospital, contracted an agency to assist in providing home health services for R1. On March 10, 2021; May 25, 2021; March 11, 2022; and March 16, 2022, from various times, from 8am to 4pm, LPA reviewed home health records, and it was reported that the beginning onset of R1’s stage 2 pressure injury was February 24, 2021, in which that was also the initial treatment for the wound. R1 had a history of lower extremities edema and sensitive skin and was totally dependent on staff for all ADL’s (assisted daily living). Home health was contacted to treat the wound and provided specific instructions for staff on proper wound care management. It was documented, on March 05, 2021, R1 sustained another wound, on the right big toe, during the time, home health was providing treatment for the initial wound. R1 already had a podiatrist for nail care, and staff were instructed to contact the podiatrist for the wound located on the toe. R1 was discharged from home health with the contracted agency on March 10, 2021 and R1’s primary insurance was to continue providing treatment. Although the allegation reported resident sustained pressure injuries while in care, R1 had resided in the facility since March 2017, and documents reviewed, revealed that the first onset of the first wound was in February 2021, observed by staff. Staff contacted the primary

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210309100124

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARBLE TERRACE	FACILITY NUMBER: 197601221
	VISIT DATE: 09/07/2022

NARRATIVE

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physician and home health services were ordered, and treatment was provided. LPA determined that the facility followed the appropriate protocols and procedures for R1, once the onset of the wound began, so there is insufficient evidence to prove resident sustained pressure injuries while in care. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview was conducted, and a copy of the report was issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC9099 (FAS) - (06/04)

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