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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602038
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:47:05 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
08/23/2023 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230823121537
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: 4DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rodrick KirkTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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1. Resident sustained a stage IV pressure injury while in care
2. Staff does not ensure resident's hygiene needs are being met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness, met with Administrator Roderick Kirk, and explained the reason for the visit. The following was determined, based on the allegations mentioned above.

Allegation # 1: It was alleged that the resident sustained a stage IV pressure injury while in care. To investigate the allegation, on 08/24/2023, from 9:45am to 11:30am, LPA requested documents and interviewed the Administrator. It was also revealed to LPA during the visit, resident # 1 (R1) was discharged and returned to the facility, the same day of the visit. Further information and documentation reviewed by LPA, revealed R1 was hospitalized from 08/21/2023 through 08/23/2023, and was discharged back to the facility, and accepted by the Administrator, with a stage 4 pressure injury. R1’s medical records also documented R1’s pressure injuries. During interviews, the Administrator admitted to LPA, that R1 had a stage IV pressure injury. LPA attempted an interview with R1 but was unable. Based on record review and interviews conducted, the allegation is Substantiated. This poses as an immediate health and safety risk to residents in care.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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 3
Control Number 31-AS-20230823121537
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: 10/19/2023
NARRATIVE
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Allegation # 2: It was alleged staff does not ensure resident’s hygiene needs are being met. To investigate the allegation, on 08/24/2023, from 945am to 1130am, LPA requested documents and interviewed the Administrator. LPA also obtained and reviewed additional documents, in conjunction with complaint investigation, control # 31-AS-20231003144903, identifying resident #1 (R1)’s personal hygiene. According to the information provided from the visit conducted on 10/11/2023, R1’s nails were observed to be long and dirty, therefore, based on the complaint visit, and documentation received, this allegation is Substantiated at this time. This poses as an immediate health and safety risk to residents in care. No citation will be issued during this visit, due to previous deficiency and citation issued on 10/11/2023 for the same allegation. Resident is no longer residing at the facility.

Exit interview, citation issued, POC letter provided, appeal rights, and copy of report provided to Administrator.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230823121537
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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2023
Section Cited
CCR
87464(d)
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Basic Services. (d) 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, evidenced by
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During today's visit, the Administrator reported to LPA, that resident #1 (R1) is currently hospitalized, and the family will be providing care after discharge, and R1 will no longer be liviing at the facility. Therefore, POC will be cleared during this visit.
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The Licensee did not comply with the regulations above by admitting and retaining a non-hospice resident #1 with prohibited health condition. This poses an immediate health and safety risk to resident(s) 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: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3