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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602540
Report Date: 02/27/2024
Date Signed: 02/27/2024 07:18:54 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
01/31/2020 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20200131112457
FACILITY NAME:PRESTIGE ASSISTED LIVING AT LANCASTERFACILITY NUMBER:
197602540
ADMINISTRATOR:MARIA MULLINSFACILITY TYPE:
740
ADDRESS:43454 30TH STREET WESTTELEPHONE:
(661) 949-2177
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:68CENSUS: 41DATE:
02/27/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Kortnie Spitzhogle, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility failed to provide proper incontinence care
Facility is unsanitary
INVESTIGATION FINDINGS:
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At 10:10am, Licensing Program Analysts (LPAs) Angela Panushkina and Huma Rahimi conducted an unannounced visit at this facility to deliver final findings. LPAs met with the Administrator and explained the reason for the visit.
Initial visit was conducted by LPA Diaz on 02/06/2020. LPA conducted an interview with the Administrator, Staff #1 (S1) and Resident #1 (R1). LPA also requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation.
During today’s visit, LPAs requested resident and staff roster. At approximately 10:30am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 11:00am – 1:30pm, LPAs conducted an interview with the Administrator, Office Manager, Nurse, Memory Care Director, former Activity Director, one staff (1), one (1) MedTech, and six (6) residents.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
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-20200131112457
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: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
VISIT DATE: 02/27/2024
NARRATIVE
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Allegation: Facility failed to provide proper incontinence care

To investigate this allegation, LPAs conducted an interview with the Administrator, Memory Care Director, Nurse and one (1) staff member and were informed that the facility provides at least two (2) showers per week and staff checks on residents every two (2) hours. However, interviews with four (4) out of six (6) residents revealed that the facility staff does not provide proper incontinent care and residents stay soiled for extended period of time. Based on interviews, this allegation is deemed Substantiated.

Allegation: Facility is unsanitary

To investigate this allegation, LPAs conducted visits to random resident rooms in a Memory Care unit and conducted an interview with a Memory Care Director and one (1) staff. Interviews with staff reveal that rooms are cleaned, and linen gets changed every day. However, upon entry to three (3) out of four (4) rooms LPAs noticed an odor. LPAs advised Memory Care Director, that although the rooms are cleaned in the morning, and the linen gets changed, staff should also be instructed to open some windows for ventilation and allow for air to circulate and relieve the rooms of foul odors, caused by resident incontinence. Based on LPAs observation of the physical plant, the allegation is Substantiated.

Deficiencies cited on LIC9099-D

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

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20200131112457
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: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2024
Section Cited
CCR
87625(b)(1-10)
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Managed Incontinence: (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:

This requirement is not met as evidenced by:
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The administrator will re-evaluate those residents who are incontinent or are assessed with toileting needs and will develop a incontinent plan after reading regulation 87625. New developed plan shall be submitted by POC date
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Based on LPAs observation and interviews, licensee failed to comply with the section cited above by leaving residents in a soiled diaper for an extended period of time, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
04/03/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation: 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 is not met as evidenced by:
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Administrator agreed to submit proof of picture or an invoice with a changed carpet in room #2. Moreover, room #3 carpet stain will be washed/removed and a proof of picture will be submitted by POC date.
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Based on LPAs observation licensee did not comply with the section cited above, by not ensuring that two (2) out of four (4) resident rooms in a Memory Care Unit were clean and free of odor. This poses/posed a potential health, safety or personal rights risk to persons 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
01/31/2020 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20200131112457

FACILITY NAME:PRESTIGE ASSISTED LIVING AT LANCASTERFACILITY NUMBER:
197602540
ADMINISTRATOR:MARIA MULLINSFACILITY TYPE:
740
ADDRESS:43454 30TH STREET WESTTELEPHONE:
(661) 949-2177
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:68CENSUS: 41DATE:
02/27/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Kortney Spitzhogle, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained unexplained injury resulting in hospitalization
Facility staff failed to notice a change in resident's condition
Facility failed to follow proper rate increase procedures for resident
Facility staff failed to meet the needs of the resident
Facility staff failed to transport resident to doctor appointment
INVESTIGATION FINDINGS:
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This is an Amendment to the original report, issued 02/27/2024, to update the allegations in the allegation box above.

At 10:10am, Licensing Program Analysts (LPAs) Angela Panushkina and Huma Rahimi conducted an unannounced visit at this facility to deliver final findings. LPAs met with the Administrator and explained the reason for the visit.
Initial visit was conducted by LPA Diaz on 02/06/2020. LPA conducted an interview with the Administrator, Staff #1 (S1) and Resident #1 (R1). LPA also requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation.
During today’s visit, LPAs requested resident and staff roster. At approximately 10:30am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20200131112457
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: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
VISIT DATE: 02/27/2024
NARRATIVE
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compliance with Title 22 Regulations. Between 11:00am – 1:30pm, LPAs conducted an interview with the Administrator, Office Manager, Nurse, Memory Care Director, former Activity Director, one staff (1), one (1) MedTech, and six (6) residents.

Allegation: Resident sustained unexplained injury resulting in hospitalization

It was alleged that, around December 2018, the facility had a motorcycle club entertainment scheduled for the residents and during that time R1 sat on a motorcycle and fell off causing an injury on his/her foot. Interview with the former Activity Director, confirmed that during that event R1 sat on a motorcycle, however, no major injuries occurred. LPA was informed that R1 had a minor scratch on a leg. Interviews with the Administrator, Memory Care Director and a former Activity Director, revealed that due to R1’s diabetes and smoking R1 developed a diabetic wound on his/her right foot. Based on interviews and record reviews, this allegation is deemed Unsubstantiated, at this time.

Allegation: Facility staff failed to notice a change in resident's condition.

To investigate this allegation, LPAs conducted an interview with the Administrator, Memory Care Director and a former Activity Director and were informed that due to R1’s diabetes and smoking R1 developed a diabetic wound on his/her right foot Review of records revealed that as of 05/2/2019, R1 was admitted on Home Health. Review of records also revealed that R1 was seen by a Would Specialist every day from 05/02/19 – 05/14/19, and every other day from 05/14/19-05/9/20. Lastly, review of hospice records revealed that R1 was placed on hospice as of 05/10/20. Based on interviews and record reviews, this allegation is deemed Unsubstantiated, at this time.

Allegation: Facility failed to follow proper rate increase procedures for resident

To investigate the allegation LPAs reviewed R1's facility file and spoke with the Administrator. The documents reviewed include: R1’s assessments, admission agreement and notices issued for rent increase to the R1’s responsible party. R1 was admitted to this facility on 04/22/2015 and record review indicated that on 11/1/2018 the first letter of rent increase was emailed and mailed to R1’s responsible party. Moreover, the 2nd rate increase letter was sent to the R1’s responsible party on November 26th, 2019. Notice indicated the new rate will be effective on February 20th, 2020. R1 did have a change in the level of care based on the initial

Continue on LIC9099-C

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20200131112457
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: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
VISIT DATE: 02/27/2024
NARRATIVE
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assessment and new assessments. LPA obtained and reviewed a copy of service rate increase notice that explained the additional charges and services to be provided. Based on interviews and record reviews, this allegation is deemed Unsubstantiated, at this time.

Allegation: Facility staff failed to meet the needs of the resident.

It was alleged that R1 requested three pictures to be hanged on the wall and the facility staff failed to meet R1’s needs. Interview with the Maintenance Director revealed that upon resident’s request, the order is being placed through a mobile application called “TELS”. Once the order is registered on TELS, the request is being completed based on a priority or as received in Queue. LPAs were also informed that R1’s request had been completed within the first week. Moreover, interviews with six (6) residents expressed no concerns regarding this allegation. Therefore, based on interviews, this allegation is deemed Unsubstantiated.

Allegation: Facility staff failed to transport resident to doctor appointment

To investigate this allegation, LPAs conducted an interview with the Administrator, Memory Care Director and were informed that based on a facility Admission Agreement, all residents are provided with a scheduled transportation to medical and dental appointments within a ten (10) mile radius. In addition, interviews with six (6) out of six (6) residents confirmed that facility does provide a transportation and all residents expressed no concerns regarding this allegation. Moreover, interview with a former Activity Director revealed that during R1’s stay at this facility, R1 had a doctor’s appointment once a month. LPA was also informed that R1 never missed an appointment nor was refused a transportation by the facility. Based on interviews and record reviews, this allegation is deemed Unsubstantiated, at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6