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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602038
Report Date: 10/11/2023
Date Signed: 10/11/2023 02:47:50 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2023 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20231003144903
FACILITY NAME:FLOWERS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197602038
ADMINISTRATOR:RODERICK KIRKFACILITY TYPE:
740
ADDRESS:2762 VISSCHER PLACETELEPHONE:
(626) 797-7996
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 5DATE:
10/11/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Roderick KirkTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff does not ensure resident's room is free of odor.
Staff does not provide adequate lighting to resident's bedroom.
Staff does not ensure resident's grooming needs are being met.
Staff does not ensure resident's urine bag is emptied.
Staff does not provide resident's bathroom with soap supplies
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted a complaint visit to the facility ito investigate the above allegations. LPAs were joined by Licensing Program Manager (LPM) Naira Margaryan for the investigation. LPAs met with the administrator, Roderick Kirk, and advised him to the complaint. Today's investigation consisted of a physical plaint inspection, interviews with staff and residents, and record review.

Staff does not ensure resident's room is free of odor:
In regards to the allegation, it was alleged that the secretions and bowel movements caused by Resident 1 (R1) is causing room to have a foul odor. Interviews with staff reveal that R1's room is cleaned and linen gets changed every day. Upon arrival at the facility, LPM Margaryan and LPAs noticed an odor at entry. LPAs advised administrator, that although the physical plant is cleaned in the morning, and the linen gets changed, staff should also be instructed to
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
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 8
Control Number 31-AS-20231003144903
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: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
VISIT DATE: 10/11/2023
NARRATIVE
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open some windows for ventilation and allow for air to circulate and relieve the physical plant of foul odors, caused by resident incontinence. Based on the LPM's and LPAs observation of the physical plant, the allegation is Substantiated. Citation issued on the 9099D. Administrator advised. Appeal rights and a copy of this report given.

Staff do not provide adequate lighting to resident's bedroom:
In regards to the allegation, it was reported that R1's room is very dim. At approximately 9:30am to 10:45am, LPA Cava conducted a physical plant. The facility has eight (8) bedrooms, of which five (5) are utilized by the residents. LPA inspected all five rooms occupied by the residents, confirming that R1' room was dim. According to staff, one of the bulbs just went out. Based on LPA's observation, the allegation is Substantiated. Citation issued on the 9099D. Administrator advised. Appeal rights and a copy of this report given.

Staff does not ensure resident's grooming needs are being met:
In regards to the allegation, it was reported that R1's nails are long and dirty. Per staff interviews, R1's nails are cleaned and cut at least once per week. LPA conducted an assessment of R1, and observed R1's nails being long and dirty. Photo was also taken on 10/11/23 (day of the investigation) as an exhibit to confirm the long and dirty nails. Based on LPAs observation, the allegation is Substantiated. Citation issued on the 9099D. Administrator advised. Appeal rights and a copy of this report given.

Staff does not ensure resident's urine bag is emptied:
In regards to the allegation, interview was made with R1's Home Health Nurse (HHN), who confirmed that they were just at the home on this date, (10/11/23), approximately an hour (between 7am and 8am) prior to the start of the LPA's investigation, and informed LPA that the urine bag was full. HHN stated they had to empty out the urine bag. When asked if staff is fully trained and instructed to empty the bag out when it becomes full, the nurse indicated yes. Based on the confirmation with the HHN, the allegation is Substantiated. Citation issued on the 9099D. Administrator advised. Appeal rights and a copy of this report given.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 31-AS-20231003144903
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: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
VISIT DATE: 10/11/2023
NARRATIVE
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Staff does not provide resident's bathroom with soap supplies:
In regards to the allegation, it was reported that the bathroom attached to R1's bedroom does not have any soap to perform proper hand hygiene. During the course of the investigation, LPA conducted a physical plant inspection between 9:30am to 10:45am. The facility has five (5) bathrooms, and confirmed at least two bathrooms, including the bathroom that is attached to R1's bedroom does not have any soap. Therefore, based on the LPA's observation, the allegation is Substantiated. Citation issued on the 9099D. Administrator advised. Appeal rights and a copy of this report given.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 31-AS-20231003144903
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: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2023
Section Cited
CCR
87303(a)
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Maintenance & Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: During the physical plaint inspection, there was a noticiable foul odor of urine or feces, upon LPM & LPA's entrance to the facility. Furthermore, during
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As POC, staff opened up the windows of the home to allow for air to circulate and relieve the physical plant of foul odors. In addition, staff will change the light bulb in R1's room to insure sufficient lighting. Proof of this will be submitted to CCL via photo by 10/18/23.
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the plant inspection, LPA confirmed that one of the light bulbs in R1's room burned out, making the room dim and not well lit. This can pose an immediate health and safety risk to the resident in care.
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Type A
10/11/2023
Section Cited
CCR
87464(d)
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Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs. This requirement was not met as evidenced by: During the investigation, LPA confirmed
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As POC, the licensee will provide staff training to insure this requirement of the regulation is met. As POC, licensee will submit proof of training via training and attendance log to CCL by 10/18/23.
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that the Home Health Nurse (HHN) had to empty out R1's urine bag. When asked if staff are trained to empty out the bag, HHN stated yes. In addition, R1's nails were observed long and dirty. This can pose an immediate health and safety risk to the resident 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 31-AS-20231003144903
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: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2023
Section Cited
CCR
87303(a)(3)(d)
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Personal Accommodations & Services: Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by:
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As POC, licensee will insure that all five bathrooms, in use by the residents in care, will be supplied with hand washing soap. As proof correction has been made, licensee will submit photos of all five bathrooms being suppled with soap to CCL by 10/18/23
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During the physical plant inspection of the facility, LPA observed at least two bathroom not supplied with hand soap, which can pose a potential health and safety risk to the 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
10/03/2023 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20231003144903

FACILITY NAME:FLOWERS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197602038
ADMINISTRATOR:RODERICK KIRKFACILITY TYPE:
740
ADDRESS:2762 VISSCHER PLACETELEPHONE:
(626) 797-7996
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 5DATE:
10/11/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Roderick KirkTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff does not provide proper care for resident's pressure injury
Staff does not reposition resident in care
Staff leaves resident soiled for extended periods of time
Staff does not provide resident with clean linen
Staff does not properly shower resident
Staff does not ensure facility is free of pests
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted a complaint visit to the facility ito investigate the above allegations. LPAs were joined by Licensing Program Manager (LPM) Naira Margaryan for the investigation. LPAs met with the administrator, Roderick Kirk, and advised him to the complaint. Today's investigation consisted of a physical plaint inspection, interviews with staff and residents, and record review.

Staff does not provide proper care for resident's pressure injury/Staff does not reposition resident in care:
In regards to the allegation, it was reported that R1 has a pressure ulcer wounds and needs constant turning and repositioning, but staff are not providing the care R1 needs. According to the Home Health Nurse (HHN), staff are instructed to reposition R1 at least every two hours to try and help heal R1's wounds. HHN nurse states she is advised by facility staff that they do so, but is not sure if staff charts or documents when they reposition R1. Interview with two (2) of two facility staff state that R1 is repositioned every two hours,
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 31-AS-20231003144903
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: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
VISIT DATE: 10/11/2023
NARRATIVE
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but no logs are entered. LPA attempted to interview R1, but R1 was unable to reply to the LPA's questions. Based on the information obtained, there was insufficient evidence to prove that Staff does not provide proper care for R1's pressure injury and Staff does not reposition resident in care. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff leaves resident soiled for extended periods of time/Staff does not provide resident with clean linen:
In regards to the allegation, it was reported that R1 is constantly soiled with bowel movement, and their incontinence care is not properly performed. It was also reported that R1's bed has been found constantly with droppings of food and unclean linen. Interviews with two (2) of two staff reveal that R1 is checked on every two hours for their incontinent needs to insure they are not soiled. If there is an incontinent need, or soiled linen, staff would change the linen right away. During the investigation, LPA conducted a plant inspection of R1's room and check and observed that R1 was not soiled during the visit. Furthermore, LPA observed staff cleaning R1's room, and R1's linen had been changed. Staff stated they also had just changed R1 clothing in the morning. LPA attempted to interview R1, but R1 was unable to reply to the LPA's questions. Based on the information obtained, there was insufficient evidence to corroborate the allegation that staff leaving R1 soiled for an extended period of time. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff does not properly shower resident:
In regards to the allegation, it was reported that R1's skin shows evidence of not being properly showered. Interview with two (2) of two staff reveal that R1 is not as mobile, therefore, R1 is given a bed bath everyday. Staff did indicate that a shower is provided as needed. LPA did a check of R1, and did not see any evidence of R1 having residue, droppings, secretions, of having a foul odor during the investigation. LPA attempted to interview R1, but R1 was unable to reply to the LPA's questions. Based on the information obtained, there was insufficient evidence to corroborate the allegation of R1 not properly getting a shower. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 31-AS-20231003144903
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: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
VISIT DATE: 10/11/2023
NARRATIVE
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Staff does not ensure facility is free of pests:
In regards to the allegation, there are cockroaches found crawling on the floor and also R1's bedside table. Interviews with five (5) of five residents could not corroborate the allegation. LPA conducted a physical plant inspection of the entire facility and did not observe any pests during the inspection. Based on the information obtained there was insufficient evidence to corroborate the allegation of facility having pests. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8