197603894-12-18-2021-31-AS-NMAN-CBN3AS-20220214170514

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603894
Report Date: 12/18/2021
Date Signed: 12/18/2021 11:58:50 AM

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
03/12/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210312121711

FACILITY NAME:	AEGIS OF GRANADA HILLS		FACILITY NUMBER:	197603894
ADMINISTRATOR:	LANCE SHENK		FACILITY TYPE:	740
ADDRESS:	10801 LINDLEY AVE.		TELEPHONE:	(818) 363-3373
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	0	CENSUS: 78	DATE:	12/18/2021
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Gina Carungao - Wellness Nurse		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained multiple fractures while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above allegation. LPA met with Welness Nurse Gina Carungao and explained the reason for the visit.

On 03/12/2021, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Dennis Douglas.

On 03/15/2021 at 1:06 PM, LPA Tan initiated the complaint visit and an Investigation Branch (IB) Investigator Douglas conducted a subsequent investigation.

(continued from LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210312121711

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: AEGIS OF GRANADA HILLS	FACILITY NUMBER: 197603894
	VISIT DATE: 12/18/2021

NARRATIVE

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(continued from LIC 9099)

Investigator Douglas’s interviews with multiple facility staff on 03/19/21, 03/23/21 and 03/24/21 revealed that Resident #1 (R1) had a recorded history of falls causing fractures and injuries prior to admission to the facility. On 02/22/21 immediately prior to admission and upon assessment, R1 was noticed to have a skin tear and hematoma on forehead resulted from a fall incident happened at home. R1 was sent to the hospital on the same day upon the recommendation of the facility staff. At the time of admission, R1 was identified to be at risk of fall and was being monitored every thirty (30) minutes or as needed and had the bed strategically placed to avoid and/or minimize the chance to fall from the bed, the recliner chair was equipped with pad alarm and the room has motion sensor alarm, all to ensure that R1 is monitored closely in the event of a fall. Staff verified that on 03/08/21, at around 8:05 AM, R1 fell from own recliner chair causing the pad alarm to activate which prompted the staff to immediately proceed to R1’s room to check. Care staff immediately called the facility Nurse to assess R1. Upon assessment, staff decided to call 911 to transport R1 to the hospital. Investigator’s interview with R1’s family member on 05/19/21 and primary Care Physician (PCP) verified the information revealed from the facility staff.

On 04/28/21 Investigator Douglas reviewed medical records previously requested from the hospital and on 06/12/21 LPA Tan reviewed available facility records. Medical records revealed that R1 sustained a fracture due to a fall. Records also indicated that “there was a small laceration in the right supraorbital area and an old forehead hematoma”.

Based on information gathered during the course of the investigation, it was concluded that although R1 suffered from the injury due to a fall, the facility provided all the precautionary measures to minimize and/or prevent R1’s fall incidents. In addition, facility personnel provided immediate attention and care to R1 when R1 fell. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021

LIC9099 (FAS) - (06/04)

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