197603165-10-10-2024-29-AS-DPEA-DAHMRY-20241029095109

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 10/09/2024
Date Signed: 10/10/2024 02:23:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2024 and conducted by Evaluator Valeria Conway

COMPLAINT CONTROL NUMBER: 29-AS-20240311081755

FACILITY NAME:	GLEN PARK AT VALLEY VILLAGE		FACILITY NUMBER:	197603165
ADMINISTRATOR:	MARILOU MENDOZA		FACILITY TYPE:	740
ADDRESS:	5527 LAUREL CANYON BLVD		TELEPHONE:	(818) 769-6626
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 42	DATE:	10/09/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	David Aguiniga		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision: Resident sustained an unstageable pressure injury while in care at the facility as a result of facility neglect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Valeria Conway, conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Administrator, David Aguiniga, and explained the reason for the visit.

On 03/11/2024, the Department received a complaint regarding an allegation of Neglect/Lack of Care and Supervision. Resident #1 (R1) sustained an unstageable pressure injury while in care at the facility. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Seng.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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 4

Control Number 29-AS-20240311081755

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE	FACILITY NUMBER: 197603165
	VISIT DATE: 10/09/2024

NARRATIVE

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Continued from LIC 9099

On 03/12/2024, from 9:10 a.m. to 4:15 p.m., LPAs Valeria Conway and Zabel Chochian conducted an unannounced 10-day complaint visit. At 10:00 a.m., the LPAs conducted a physical plant tour of the facility with the Assistant Administrator to ensure there were no health and safety hazards. From 11:05 a.m. to 1:15 p.m., the LPAs conducted records review including but not limited to resident records, facility internal records and obtained copies of pertinent documents relevant to the investigation.

On 04/14/2024, from approximately 4:31 p.m. to 5:13 p.m., Investigator Seng conducted interviews with R1’s Resident Representative and Kaiser Permanente Clinical Social Worker; on 05/16/2024, from approximately 8:47 a.m. to 10:58 a.m., with the facility Assistant Administrator, caregivers, and residents; on 06/11/2024, from approximately 4:50 p.m. to 5:54 p.m., with caregiver and an attempted interview with R1 (R1 unable to be interviewed due to mental condition of dementia and non-verbal); and on 06/12/2024, at approximately 2:01 p.m., with Star World Home Health nurse. In addition, the investigator obtained and reviewed medical records from Kaiser Permanente, Astoria Nursing and Rehabilitation Center, Grand Valley Health Care Center, and Star World Home Health, photos of R1’s pressure injury, and facility file documents related to the investigation.

According to medical records reviewed, R1 was initially admitted to the Grand Valley Health Care Center (GVHCC) on 12/23/2022 for a left femoral neck fracture (hip fracture). On 01/25/2024, R1 was discharged and admitted to the Glen Park at Valley Village facility. The discharge paperwork from GVHCC did not indicate a pressure injury. However, GVHCC records reviewed indicated that on 01/11/2024, R1’s Patient Care Plan notated R1 had a pressure injury on R1 Sacro coccyx which was listed as a Stage 2. The goal was to ensure the sore was healed within 90 days. The Assistant Administrator stated R1 had no pressure injuries upon admission to the facility, however, it is unknown if a body check was completed. During R1’s file review it was noted R1’s Head to Toe Assessment form was not filled out and left blank, both in the file review and when the investigator requested to view the documents in person.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20240311081755

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE	FACILITY NUMBER: 197603165
	VISIT DATE: 10/09/2024

NARRATIVE

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Continued from LIC 9099-C

R1’s diagnosis included osteoporosis of knee, myopia, difficulty with walking, diplopia, hypertension, fracture of left femur, history of falling, hyperlipidemia, insomnia, low back pain, lack of coordination, artificial left hip joint, radiculopathy of cervical region, arthritis, senile degeneration of brain, spinal stenosis of lumbar region, spondylolisthesis of lumbar region, type two diabetes, dementia, and glaucoma.

A review of the Star World Home Health records revealed R1’s care with home health began on 01/30/2024, the home health nurse reported a Stage 2 pressure injury on R1’s coccyx measuring 0.3x0.2x0.2cm. A Physician’s Order from Dr. David Wong recommended a Skilled Nursing visit one time a week for 3 weeks. Dr. Wong’s order stated the following, “Skilled Nurse to perform/demonstrate and instruct patient/caregiver regarding coccyx pressure ulcer as follows: cleanse with wound cleanser, pat dry, apply triad paste and leave open to air daily. Patient caregiver may perform treatment during non-Skilled Nurse visit days. Coccyx pressure ulcer will be healed with current treatment by 4 weeks. Wound will remain free from signs and symptoms of infection, or complications during the treatment period”. The administrator was made aware of and agreed to the treatment plan. The home health notes indicate by the 02/15/2024 visit, the pressure injury increased in size and progressed in size weekly thereafter. By 03/01/2024, R1 was sent to Kaiser Permanente Emergency Room (ER) for further evaluation and diagnosed with a pressure ulcer of sacrum Stage 3 with full thickness skin loss. Later that same day, R1 was discharged from Kaiser and admitted to Astoria and Nursing Rehabilitation Center to continue with wound care. R1 was diagnosed with a pressure injury of sacral region unstageable.

Based on record review and interviews conducted, the Department did not find sufficient evidence to prove that the facility was responsible for the neglect/lack of care and supervision causing R1 to sustain an unstageable pressure injury. Per the staff interviews, it is possible that the Star World Home Health (HH) nurse failed to properly care for R1. The staff interviews reflected that R1 was a “two-person assist;” however, the HH nurse never asked for assistance. Other staff interviews reflected that the HH nurse was only seen twice at the facility and others stated that sometimes the HH nurse would not visit R1 as the HH nurse would only discuss R1’s condition with the Assistant Administrator. The HH nurse did not provide information or documentation to support which caregivers were provided with training on R1’s wound care.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240311081755

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE	FACILITY NUMBER: 197603165
	VISIT DATE: 10/09/2024

NARRATIVE

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Continued from LIC 9099-C

The caregivers should not provide wound care given they are not skilled professionals. Based on the evidence received from staff, HH nurse interviews, and the medical records; there was insufficient evidence to prove that the allegation of neglect and lack of care and supervision of the R1’s pressure injury became worse due to staff neglect/lack of supervision. Therefore, the allegation “Neglect/Lack of Care and Supervision: Resident sustained an unstageable pressure injury while in care at the facility as a result of facility neglect” is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

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