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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 09/22/2021
Date Signed: 09/22/2021 12:59:00 PM



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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20210825165202
FACILITY NAME:A HEAVENLY HAVEN, INC.FACILITY NUMBER:
197605522
ADMINISTRATOR:FRANCISCA M. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Francisca Recede, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff does not allow authorized representative visitation.
Facility staff does not wear a mask.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit to deliver the investigation finding for the above allegations. The LPA met with administrator Francisca Recede at 10:03 a.m. and explained the reason for the visit.

During today’s visit, the LPA conducted a physical plant tour from 10:05 a.m. until 10:33 a.m. to ensure there are no health and safety hazards.
On 08/30/21, LPA Walker conducted an initial complaint visit. Between 10:07 a.m. and 5:00 p.m., the LPA conducted a physical plant tour, medication review, interviewed residents, staff, and administrator; as well as reviewed and obtained copies of documents pertinent to the investigation. The LPA determined, at that time, that further investigation was required.

Continued on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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 5
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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20210825165202

FACILITY NAME:A HEAVENLY HAVEN, INC.FACILITY NUMBER:
197605522
ADMINISTRATOR:FRANCISCA M. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Francisca Recede, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility staff not providing assistance to resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit to deliver the investigation finding for the above allegations. The LPA met with administrator Francisca Recede at 10:03 a.m. and explained the reason for the visit.
During today’s visit, the LPA conducted a physical plant tour from 10:05 a.m. until 10:33 a.m. to ensure there are no health and safety hazards. From 11:28 a.m. and 11:48 a.m., the LPA conducted interviews with family members of residents living at the facility.
On 08/30/21 from 10:07 am. until 10:30 a.m., the LPA conducted a physical plant tour. From 10:30 a.m. until 11:00 a.m., the LPA conducted a medication review. Residents were interviewed between 11:00 a.m. and noon. The LPA interviewed the administrator and staff between noon and 1:00 p.m.
Regarding the allegation, ‘Facility staff not providing assistance to resident in a timely manner,’ the complainant’s concern is that while resident #1 (R1) was on the phone with a family member, the family member could hear R1 calling out for assistance, but no one arrived until an hour later.
Continue on LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20210825165202
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A HEAVENLY HAVEN, INC.
FACILITY NUMBER: 197605522
VISIT DATE: 09/22/2021
NARRATIVE
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During the investigation, the LPA conducted interviews with residents, resident’s family members, staff, and the administrator. Interviews with residents revealed that staff check on the residents approximately five times a day, and whenever residents call them. Interviews with staff revealed that residents are monitored every two hours or more. Interview with the administrator revealed that R1 calls out for help even when the staff are in the process of assisting. The LPA confirmed the statement from the administrator, based on observation R1 continuously called out for help while being feed, assisted using the toilet, and transferring in and out of the facility’s couch recliner. The LPA observed R1 saying ‘don’t hit me’ to staff during the visit, while staff was not touching R1.

Based on interviews with residents, resident’s family members, and the administrator, there is insufficient evidence to support the allegation ‘Facility staff not providing assistance to resident in a timely manner.’ Therefore, this allegation is deemed Unsubstantiated at this time.

Exit Interview conducted, a copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20210825165202
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A HEAVENLY HAVEN, INC.
FACILITY NUMBER: 197605522
VISIT DATE: 09/22/2021
NARRATIVE
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Regarding the allegation, ‘Facility staff does not allow authorized representative visitation’, the complainant’s concern is that the facility only allowed outside window visits until recently. The complainant’s concern is that staff are being instructed by resident #1’s (R1’s) family to not allow indoor visitation.
During the investigation, the LPA conducted interviews with the administrator, and R1’s family members who revealed that indoor visitation has only been allowed as recently as 06/08/2021. When the LPA interviewed the administrator, the administrator confirmed that indoor visitation was only recently allowed. The Administrator stated that the reason for no indoor visitation being allowed, was due to the facility following CDSS PINs, and to avoid the spread of COVID-19. The LPA advised the administrator of updated CDSS PIN 21-17.2-ASC which was issued on 05/14/2021 allowing indoor and in-room visitation at all times and for all residents, regardless of vaccination status of the resident or visitor. Although the facility allows indoor visitation at this time, when PIN 21-17.2-ASC was released (05/14/2021), the administrator still refused to allow indoor visitation as required. Indoor visitation was not allowed until 06/18/2021 to resident family members based on record review.
Based on record review, interviews with administrator, and R1’s family members, there is sufficient evidence to support the allegation ‘Facility staff does not allow authorized representative visitation.’ Therefore, this allegation is deemed Substantiated at this time.
Regarding the allegation, ‘Facility staff does not wear a mask’, the complainant’s concern is that staff remove their face covering inside the facility and is placing resident’s health at risk for contraction of COVID-19.
During the visit on 08/30/21, the LPA observed one facility staff removing their face mask on different occasions inside the facility, while in close proximity of the residents in care. The LPA advised the Administrator and the staff that the facility must follow all CDC guidelines and CDSS regulations; and, that failure to comply with Title 22 Regulations would result in citations with the possibility of civil penalties. On August 19, 2021, PIN 21-38-ASC (Supersedes PIN 21-12-ASC and PIN 21-17.2-ASC in part) MASKING REQUIREMENTS FOR ASC RESIDENTIAL FACILITIES: Consistent with the current CDPH face mask guidance and the State Public Health Officer Order of July 26, 2021, facility staff shall wear masks at all times.
Based on LPAs observations, interviews with administrator, staff, and resident family members, there is sufficient evidence to support the allegation ‘Facility staff does not wear a mask.’ Therefore, this allegation is deemed Substantiated at this time.
The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20210825165202
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A HEAVENLY HAVEN, INC.
FACILITY NUMBER: 197605522
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2021
Section Cited
CCR
87468.1(a)(11)
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87468.1(a)(11) Personal Rights of Residents in All Facilities: (a) Residents in..facilities for the elderly shall have..personal rights:(11)To have their visitors..permitted to visit privately..without prior notice..

This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:1. Administrator, and staff will review PIN 21-17.2-ASC issued on 05/14/2021.
2.Facilty will continue to allow indoor visitation following the update PIN 21-40-ASC, and apply updated changes.
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Based on interviews and records reviewed, the Licensee did not comply with the section cited above, as the Licensee failed to ensure that residents in residential care where allowed to have their visitors, which poses a potential health and safety risk to residents in care.
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Type B
09/22/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations..
This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1. Submit staff retraining log on Infection Control PIN 21-38-ASC regarding masks wearing in the facility to LPA by 09/29/21.
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Based on observation, and interviews conducted, the Licensee did not comply with the section cited above, as the Licensee failed ensure that one facility staff wear face coverings while providing care and supervision to residents in care, which poses a potential health and safety risk to residents 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5