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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602540
Report Date: 03/28/2024
Date Signed: 03/28/2024 05:54:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
02/28/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20240228142941
FACILITY NAME:PRESTIGE ASSISTED LIVING AT LANCASTERFACILITY NUMBER:
197602540
ADMINISTRATOR:MINDY MENDOZA-PERRYFACILITY TYPE:
740
ADDRESS:43454 30TH STREET WESTTELEPHONE:
(661) 949-2177
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:68CENSUS: 46DATE:
03/28/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide adequate incontinent care
Staff are mishandling the residents medications
Staff did not address the flooding issues on the facility grounds
Staff do not respond to the residents timely
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/28/2024 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival LPA met with the Executive Director, Kortnie Spitznogle and LPA explained the purpose of the visit. Kortnie Spitznogle informed LPA that Analilia Zargoza is th current administrator. Entrance interview conducted.

At approximately 2:00 p.m. Licensing Program Analyst (LPA) Evelin Rios, conducted a physical plant tour of the facility to ensure the health and safety of the residents in care. Before the physical plant tour LPA requested the resident roster, copies of staff #1's (S1) medication training, resident #2 (R2) record and insurance information for the facility's van. From 2:30 p.m. to 4:17 p.m. LPA conducted interviews with five (5) residents and four (4) staff. From approximately 3:35 p.m. LPA reviewed records gatherd on todays visit and documents gathered on the intial visit conducted by LPA Spaeth on 02/29/2024.
(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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 6
Control Number 31-AS-20240228142941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
VISIT DATE: 03/28/2024
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
(Continued from LIC9099)
Allegation: Facility did not provide adequate incontinent care. It is alleged residents are left to sit in their soil undergarments. To investigate this allegation, LPA Rios reviewed Complaint Control #31-AS-20200131112457 with the allegation; facility failed to provide proper incontinence care. On 02/27/2024 LPAs Angela Panushkina and Huma Rahimi conducted interviews with six (6) residents and based on four (4) resident interviews the allegation was deemed substantiated at the time. Due to the both allegations involving incontinent care this allegation is deemed Substantiated. The facility has submitted a plan of correction that was received and cleared by LPA Panushkina on 03/04/2024 no citation will be issued on today’s visit.

Allegation: Staff are mishandling the residents medications. To investigate the allegation LPA reviewed an incident report submitted to Community Care Licensing (CCL) for an incident that occurred on 03/04/2024. Mentioned on the incident report was that resident #2 (R2) was given another resident's medication. According to the report staff #1 (S1) was preparing medication for R2 when they were called away to provide assistance. When S1 retuned they continued to pass medication to R2. S1 shortly after realized they had provided the wrong medication to R2. LPA's interview with staff Jesse Wong revealed S1 received a re training from him that included reviewing previous medication training. LPA's review of S1 records revealed they received their initial medication training on 12/29/2021 and an annual training on 02/21/2022. Based on the information reviewed this allegation is deemed Substantiated at this time.

Allegation: Staff did not address the flooding issues on the facility grounds. It is alleged a room in the memory care unit had a flood and the facility has not dealt with it. To investigate the allegation LPA Rios conducted a tour of room #2 at approximately 2:50 p.m. in the designated memory care unit and observed the carpet still had extensive water damage. LPA observed some carpet pulled up from the entrance of the room and fans in the room used to dry flooring. LPA smelled a musty odor in the room. Interview with staff #2 (S2) revealed the room had a flood that originated from it's bathroom and the facility is working on remodeling the room. Room is currently vacant and is kept locked. Based on observations this allegation is deemed Substantiated at this time.

(Continue to LIC9099) (Page 2 of 3)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20240228142941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2024
Section Cited
HSC
87465(d)(3)
1
2
3
4
5
6
7
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication,[...] facility staff designated by the licensee, shall be permitted to assist the resident with self-administration[...] This requirement was not met as evidence by,
1
2
3
4
5
6
7
Facility conducted their own investigation and had in-house training for S1 after the incident was reported. Executive Director provided copy of training dated 3/04/2024 to LPA. Facility conducted training with all staff. Administrator will send training documents by POC date to LPA.
8
9
10
11
12
13
14
Based on LPAs interviews, and record review the licensee failed to comply with the section cited above due to S1 giving R2 another resident's medication, which poses/posed an immediate health, safety or personal rights risk to persons in care
8
9
10
11
12
13
14
Type B
04/05/2024
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by,
1
2
3
4
5
6
7
Administrator will re-evaluate the rooms in the memory care unit and submit a timeline of when the repairs will be made.
8
9
10
11
12
13
14
Based on LPAs observation the licensee failed to comply with the section cited above by not addressing the water damage in room #2 and having call buttons and pendents not functioning properly, which poses/posed an potential health, safety or personal rights risk to persons in care
8
9
10
11
12
13
14
Administrator will specifically address the repairs taking place in room #2 and verify all call button and pendents are working properly, send information to LPA by POC due date 04/05/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20240228142941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
VISIT DATE: 03/28/2024
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
Allegation: Staff do not respond to the residents timely. It was alleged residents are left to wait for staff to respond to them for assistance. To investigate the allegation LPA Rios observed S2 push the call buttons in room 101 two out of the three button affixed on the wall did not light indicated the batteries needed to be replaced. In room 105 with permission, LPA pressed the pendent on the resident's neck, after a few minutes staff #3 was called to disregard the call, S3 informed the indicator did not go on. Furthermore interviews with staff revealed this had been an issue discussed and the facility had already taken action to remedy the situation by testing all call buttons and replacing batteries when needed. LPA interviews with two (2) out of (5) residents revealed they had had experienced long wait times but they have not experienced it recently. Based on interviews and observation this allegation is deemed Substantiated at this time.


Deficiencies cited on LIC9099-D

Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6