197605522-4-1-2022-29-AS-JAPL-CDF2SB-20220412173851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 03/30/2022
Date Signed: 04/01/2022 04:21:41 PM

Unsubstantiated

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
10/27/2021 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20211027135843

FACILITY NAME:	A HEAVENLY HAVEN, INC.		FACILITY NUMBER:	197605522
ADMINISTRATOR:	FRANCISCA M. RECEDE		FACILITY TYPE:	740
ADDRESS:	5504 FALLBROOK AVENUE		TELEPHONE:	(818) 713-0447
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 3	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Yuliya Asatryan		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff injured resident while in care.

INVESTIGATION FINDINGS:

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On 03/30/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the above allegation. The LPA arrived at the facility at 1:00 p.m. LPA Urena met with staff, and explained the reason for the visit. The staff called the administrator on the phone. The LPA spoke with the administrator Yuliya Asatryan via phone and explained the reason for the visit, and the administrator stated that they were an hour away from the facility. The LPA read the report over the phone, and administrator stated that the staff would sign the report on their behalf.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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 3

Control Number 29-AS-20211027135843

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: 03/30/2022

NARRATIVE

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On 10/28/2021 at 1:15 p.m., Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial 10-day complaint investigation visit to the facility. LPA Urena was greeted by staff. The LPA introduced herself. Staff called administrator to inform them of the visit. At 1:40 p.m., LPA Urena met with Administrator Francisca Recede, and explained the reason for the visit. From 1:20 p.m. to 3:00 p.m., LPA Urena conducted interviews with staff, residents, and responsible parties. From 3:00 p.m. to 3:30 p.m., LPA Urena reviewed facility records. The LPA determined that further investigation was needed at that time.

Regarding the allegation that ‘Staff injured resident while in care’, it is alleged that R1 had bruising on their hand on Friday and then another bruise on top of the first bruise on another day. The Reporting Party’s (RP’s) concern is that R1 is being hurt at the facility by staff. RP stated that R1 informed them that Staff #1 (S1) had hurt R1; but, when the RP asked R1 again about who hurt R1, R1 did not remember. Per the RP, R1 has dementia. According to the RP, the staff act like they don’t know what happened.

To investigate this allegation, the LPA interviewed staff, administrator, residents and residents’ responsible party. On 10/28/2021, upon arrival at the facility, the LPA noticed R1 sitting on a reclining chair in the living room area. Two other residents were also sitting in reclining chairs in the living room area. At 1:20 p.m., the LPA introduced herself to R1. The LPA asked R1 about the bruise on their hand, but R1 could not tell the LPA how the bruise happened. R1 stated that ‘somebody is beating me up when I’m asleep’. The LPA asked how R1 was doing? R1 sated, ‘I’m doing ok’. While the LPA was interviewing R1; S1 came to attend to one of the other two residents sitting in the reclining chairs in the living room. S1 was close enough to R1, and the LPA asked if R1 knew who S1 was? R1 stated, ‘he is my friend, I like him, I don’t love him, I like him’.

From 1:30 p.m. to 2:30 p.m., the LPA conducted interviews with staff and the administrator. At 1:30 p.m., the LPA asked S1 about the bruise on R1’s hand. S1 stated that it was S1’s day off and they were not present when the bruise happened. At 1:45 p.m., the LPA asked Staff #2 (S2) about the bruise on R1’s hand and S2 stated that around 1:00 a.m. on 10/24/2021, R1 screamed, and S2 went to see R1 in the bedroom. According to S2, R1 seemed to be having a bad dream. Per S2, they asked R1 what happened, and R1 stated they were having a nightmare. S2 added that they went back to bed after they made sure everything was ok with R1. S2 added that the same day, at around 7:00 a.m., when they were changing R1 and giving R1 a sponge bath, they noticed the bruise on R1’s left hand. S2 stated that they wrote a report and informed the administrator of the bruise at around 8:00 a.m. According to S2, the administrator instructed S2 to apply a warm compress to the top of the left hand. The bruise was about the size of a quarter.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20211027135843

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: 03/30/2022

NARRATIVE

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At 2:12 p.m., the LPA interviewed the administrator about the bruise on R1’s hand. The administrator stated that S2 had informed them of the incident of R1 having a nightmare on Sunday morning, and about the bruise. The administrator added that R1 is on an aspirin regimen, which causes R1 to bruise very easily. The administrator added that R1 gets agitated easily, and moves R1’s hands a lot, which may bump against the table, bed, and half bed rail. The administrator stated that they usually apply warm compresses to all residents that are prone to bruising due to medication. Additionally, the administrator stated that they checked R1 on Monday, 10/25/2021, and R1 seemed to be doing well. The administrator added that on 10/26/2021, the administrator was at the facility, and the RP was visiting R1. The administrator stated that the RP never asked about the bruise on R1’s hand, or what happened.

From 2:30 p.m., to 3:00 p.m., the LPA interviewed residents and residents’ responsible parties. The interviews with residents revealed that they are doing well, and that staff take care of them, ‘they (staff) are very nice’. The interviews with responsible parties for the residents revealed that they were happy with the staff providing the care, that the residents seem to be happy, ‘they always take good care of all the residents. When the LPA asked responsible parties if they had noticed any suspicious, or unexplained bruising, and they stated that they knew that the residents can bruise easily; and, the bruises they have seen are what they call ‘normal bruising’, such as when ‘transporting the resident from the wheelchair to the van’, where the resident accidently bumps their legs

Based on the interviews, and record review, there is insufficient evidence to support the claim that ‘Staff injured resident while in care’. Therefore, this allegation is deemed Unsubstantiated at this time’.

Exit interview conducted, today's report was reviewed. Signatures were obtained. Report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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