197605522-4-1-2022-29-AS-JAPL-CDF277-20220412170815

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 03/30/2022
Date Signed: 04/01/2022 04:15:22 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
08/18/2021 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20210818134552

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:	Francisca Recede		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained unexplained bruises while in care.
Staff refused to assist resident with meals.
Staff did not attend to resident in a timely manner.
Licensee did not make resident’s records available to resident's responsible person.
Staff cut resident's hair without the consent of the responsible person.

INVESTIGATION FINDINGS:

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This is an amended report. Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint investigation visit regarding the above noted allegations. At 1:00 p.m., LPA Urena arrived at the facility, spoke with the Administrator, and explained the reason for the visit.

On 9/22/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an announced initial 10-day complaint investigation visit regarding the above noted allegations. At 2:00 p.m., the LPA arrived at the facility. At 2:45 p.m., the LPA met with Administrator and explained the reason for the visit. At 2:30 p.m. the LPA interviewed Staff 1(S1), Staff 2(S2), and Administrator.

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)

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Control Number 29-AS-20210818134552

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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Regarding the allegation, ‘Resident sustained unexplained bruises while in care’. It is alleged that R1 sustained a bruise on their right hand. The Reporting Party (RP) was informed by S1 that R1 sustained the bruise on the right hand while moving about in the bed and hitting their hand against the bedrail. Additionally, RP stated that S1 said that R1 also sustained bruises while R1 was visited by RP; and, RP denied this statement. On the date the RP observed the bruise on the right hand of R1, the RP called 9-1-1 to inform them of R1’s bruises. Law enforcement responded to the call and conducted a health and safety check. Law enforcement stated to RP that ‘no issues were found’. RP was told by law enforcement that no report would be generated.

To investigate this allegation, the LPA interviewed staff, administrator, residents and residents’ responsible parties. LPA Urena attempted to interview R1 about the bruise on the right hand, but R1 was unable to answer the question about what happened to the hand. The bruise was small in size, about the size of a quarter, and located on the top of the hand between the thumb and the index finger. The LPA asked R1 questions about their wellbeing and the care they receive from staff at the facility. The R1 stated that they liked the staff, that they love them, and was fine. Interviews conducted with staff revealed that R1 at times gets agitated and bumps hands and legs against the half bedrail. The LPA conducted a records review and the LPA did not find evidence of an Incident Report or doctor’s notes pertaining to bruising or medical attention needed. The LPA observed that the R1 is on an aspirin regimen which causes R1 to easily bruise. During the visit, the LPA observed R1 to be agitated, arms moving up and down, and saying to staff in a very loud voice, ‘you are making me dizzy, you are making me dizzy’, over and over, while staff was transferring R1 from the facility’s recliner chair to the wheelchair, and before being wheeled to the bathroom. Based on observing this behavior, R1 could have accidently bumped their hand on the wheelchair or the bedrail, which sustained a bruise. Interviews with other residents and their responsible parties revealed that they have not experienced or witness unexplained bruises on hands or other parts of their residents’ bodies.
Based on the interviews, and record review, there is insufficient evidence to support the claim that the ‘Resident sustained unexplained bruises while in care’. Therefore, this allegation is deemed Unsubstantiated at this time.

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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Control Number 29-AS-20210818134552

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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Regarding the allegation, ‘Staff refused to assist resident with meals.’ It is alleged that R1 had food dripping off their mouth, and staff refused to assist. RP states that R1 has dementia and is supposed to be assisted with meals. To investigate this allegation, the LPA interviewed staff, administrator, and residents’ responsible parties. Interviews with staff, and administrator revealed that residents are assisted with meals; and, as needed. The LPA interviewed R1 to address the allegation, but when asked about the being assisted with meals, the R1 stated, ‘I can do it myself’. The LPA interviewed facility residents, but the residents were unable to provide information. The LPA interviewed residents’ responsible parties and found that the responsible parties stated that they have witness staff assisting residents with their meals, taking them to the bathroom, and moving them from place to place. Additionally, responsible parties stated, ‘staff always take good care of all the residents’ wellbeing.
Based on interviews with staff, administrator and resident’s family members, there is insufficient evidence to support the allegation that the ‘Staff refused to assist resident with meals.’ Therefore, this allegation is deemed Unsubstantiated at this time.

Regarding the allegation, ‘Staff did not attend to resident in a timely manner’. It is alleged by RP that R1 asked for cold water and it took more than 45 minutes for staff to arrive to the room. It is also alleged that staff told RP that they were watering the plants and that's why it took so long. To investigate this allegation, the LPA Interviewed staff, administrator, residents, and residents’ responsible parties. Staff interviews revealed that staff check on the residents approximately five times a day, and whenever residents call them. When asked if it took staff 45 minutes to provide R1 with water because they were watering plants, the staff stated that they did not take that long to provide the water. Staff stated that they took about fifteen minutes, because they were attending to the other residents. The LPA then interviewed R1 about the timeliness of staff responding to their needs, but R1 could not provide information.
The LPA interviewed residents’ responsible parties, and they reported that they are pleased with the services rendered to their family members. ‘staff attend to the residents in a timely manner’. Additionally, residents reported that staff attend to their needs when called and check on their needs throughout the day.

Based on the investigation, there is insufficient evidence to support the claim that ‘Staff did not attend to resident in a timely manner’. Therefore, this allegation is deemed Unsubstantiated at this time.

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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Control Number 29-AS-20210818134552

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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Regarding the allegation, ‘Licensee did not make resident’s records available to resident's responsible person’. It is alleged that the RP asked staff several times if they could review R1’s medication list, and other records, but staff refused to let RP see them, with no explanation provided.

To investigate this allegation, the LPA interviewed the administrator, conservator, and conducted a records review. The interview with the administrator revealed that the RP is not the responsible party for R1, consequently, the RP was not given permission to review R1’s file. The LPA found in R1’s file that R1 has a conservator. Per interview with conservator, resident’s records are available to the conservator.

Based on the investigation, although the licensee did not make R1’s records available to the reporting party, they did make the records available to the resident’s responsible person, who is the conservator. Therefore, this allegation is deemed Unsubstantiated at this time.

Regarding the allegation, ‘Staff cut resident's hair without the consent of the responsible person’. It is alleged that R1 was given a hair cut by staff without RP being notified. RP stated, ‘R1 would never want short hair and staff cut the hair above ear level similar to a boy's cut’. However, the RP is not R1’s responsible person; that falls under the conservator’s duties.

To investigate this allegation the LPA interviewed R1, staff, and administrator about the hair cut given to R1. The LPA asked R1 about the haircut and R1 stated that they did not know who cut their hair. The staff interviewed revealed that they were not aware of who gave permission to cut R1’s hair. The administrator’s interview revealed that depending on the residents’ ability to make decisions, they may give permission themselves, or a family member may give permission for haircuts. In the case of R1’s haircut, the administrator stated that the spouse of R1 gave permission for R1’s haircut. This permission was given when the R1’s spouse was the responsible party for R1. The LPA attempted to interview R1’s spouse, but was unable to reach them for comment. Consequently, there is insufficient evidence to identify who gave permission for the haircut. The LPA interviewed R1 about the haircut, and the R1 stated that someone cut their hair, and that they were ‘ok’ with it.Based on the investigation, there is insufficient evidence to support the claim that ‘Staff cut resident's hair without the consent of the responsible person’. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted, today's report was reviewed with staff. 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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