197602038-12-16-2024-31-AS-RORN-DC3UD7-20241218142905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602038
Report Date: 12/16/2024
Date Signed: 12/16/2024 05:43:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
11/09/2023 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20231109171453

FACILITY NAME:	FLOWERS RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	197602038
ADMINISTRATOR:	RODERICK KIRK		FACILITY TYPE:	740
ADDRESS:	2762 VISSCHER PLACE		TELEPHONE:	(626) 797-7996
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	6	CENSUS: 0	DATE:	12/16/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:			TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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1. Staff did not ensure that the facility shall maintained a separate, complete, and current record for each resident in the facility
2. Staff did not ensure that the facility retained original records for a minimum of three (3) years following termination of service to a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness attempted to conduct a subsequent visit to deliver the final complaint report for the allegations mentioned above. Upon arriving to the facility, LPA observed the property empty, and contractors working on the property. According to information obtained from recent visits, the facility is no-longer operating as a RCFE. The former Administrator Roderick Kirk, contacted Licensing to obtain information how to close the facility. As of today, CCL has not received any official written notice from Administrator, and there have been numerous attempts attempts to contact the Administrator via-phone, and the department has not been successful. At this time, the complaint investigation has been concluded, and the following was determined:

Allegation # 1: It was alleged staff did not ensure that the facility shall maintained a separate, complete, and current record for each resident in the facility. . On 11/16/2023, between 11:00 a.m. and 12:00 p.m., (LPA) conducted an initial visit to the facility to investigate the allegation. During the visit, (LPA) interviewed the Administrator and reviewed documentation related to the allegation. According to the complaint,

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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 3

Control Number 31-AS-20231109171453

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FLOWERS RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 197602038
	VISIT DATE: 12/16/2024

NARRATIVE

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on 07/14/2023, the Long-Term Care Ombudsman (LTCO) visited the facility to request information regarding a former resident (R1) who previously resided at the facility. At the time of the visit, the Administrator was unable to locate (R1’s) resident file. The LTCO reported that despite multiple follow-up attempts, the requested information was not provided. During the investigation on 11/16/2023, the Administrator admitted that the facility did not maintain resident records, including (R1’s) file. When (LPA) requested (R1’s) records, the Administrator was unable to produce the requested documents during the visit. However, LPA later received some documents related to (R1). Based on interviews conducted and documentation reviewed, the allegation that the facility failed to maintain a separate, complete, and current record for each resident is Substantiated.

Allegation # 2: It was alleged that the facility failed to retain original resident records for a minimum of three (3) years following the termination of a resident’s service, as required by regulations. On 11/16/2023, between 11:00 a.m. and 12:00 p.m., Licensing Program Analyst (LPA) conducted an initial visit to the facility to investigate the allegation. During the visit, (LPA) interviewed the Administrator and reviewed documentation related to the allegation. According to the complaint, on 07/14/2023, the Long-Term Care Ombudsman (LTCO) visited the facility to request information regarding a former resident (R1) who previously resided at the facility. During the LTCO’s visit, the Administrator was unable to locate (R1’s) resident file. During (LPA’s) investigation on 11/16/2023, the Administrator acknowledged that the facility did not maintain original resident records, including (R1’s) file, as required. Subsequently, the Administrator submitted some documents related to (R1) to (LPA); however, these records were incomplete and not accurately filled out. Based on interviews conducted and documentation reviewed, the allegation that the facility failed to retain original resident records for a minimum of three (3) years following termination of a resident’s service is Substantiated.

**Note, due to the recent closure of the facility and the department not able to contact the former Administrator, signatures were not able to be obtained for reports, and plan of corrections for citations have been cleared. No further action is needed and reports will be emailed to Administrator that is on file with CCL.

Citations issued, POC's cleared.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 31-AS-20231109171453

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 12/16/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/16/2024 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement was not met, evidenced by: during the investigation it was revealed by the	1 2 3 4 5 6 7	LPA received the personnel records for resident # 1. POC cleared.
	8 9 10 11 12 13 14	the Administrator admitted that the facility did not maintain resident records, including R1’s file. This poses as a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 12/16/2024 Section Cited CCR 87506(e)	1 2 3 4 5 6 7	Resident Records. (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met, evidenced by: during the investigation it was revealed by the Administrator	1 2 3 4 5 6 7	LPA received the personnel records for resident # 1. POC cleared.
	8 9 10 11 12 13 14	was unable to produce the requested documents during the visit.. However, LPA later received some documents related to R1. This poses as a potential health and safety risks to residents in care.	8 9 10 11 12 13 14

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

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