197605522-10-11-2022-29-AS-JAPL-CKK2JN-20221025172633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 10/11/2022
Date Signed: 10/11/2022 05:04:27 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
03/01/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220301110139

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: 4	DATE:	10/11/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Yuliya Asatryan		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care
Resident sustained a bruise while in care
Facility does not meet resident's nutritional needs
Staff spoke inappropriately in the presence of resident
Staff do not assist resident with ambulation
Staff did not seek medical care for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent complaint visit to deliver the findings for the above allegations. The LPA met with Administrator Yuliya Asatryan and explained the reason for the visit.

During the initial visit conducted on 3/2/2022, LPA Smith reviewed files at 9:00 a.m., interviewed staff at 8:34 a.m., 9:39 a.m., and 10:03 a.m.

Regarding the allegation: Resident sustained multiple pressure injuries while in care
On 3/1/2022, the Department received a complaint which alleged that Resident #1 (R1) sustained multiple pressure injuries while in care. It was alleged that R1 was observed to have fifty (50) open wounds. On 3/2/2022, LPA Ashley Smith initiated the initial visit with Administrator Yuliya Asatryan. LPA Smith reviewed files at 9:00 a.m., interviewed staff at 8:34 a.m., 9:39 a.m., and 10:03 a.m.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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-20220301110139

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: 10/11/2022

NARRATIVE

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Allegation: Resident sustained multiple pressure injuries while in care
It was alleged that when R1 arrived at the hospital, R1 was observed to have sustained over fifty (50) open wounds due to facility staff neglect. A review of medical documents and nursing notes did not display concern or evidence of the alleged pressure injuries, facility negligence or abuse against R1. Interviews confirmed that R1 had not sustained wounds, but that the resident had dry and sensitive skin. The complainant provided the LPAs a photograph; however, there was no date or time stamp on the photo, nor was there any evidence that the photograph was of R1. In addition, the photograph did not display open pressure injuries. Therefore, there is insufficient evidence to support the claim that R1 sustained pressure injuries; and or, that failure to provide adequate care and supervision resulted in fifty (50) open wounds to R1’s body. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident sustained a bruise while in care

On 3/1/2022, the Department received a complaint which alleged that Resident #1 (R1) sustained a bruise while in care. It was alleged that R1 sustained a bruise on their left hand. On 3/2/2022, LPA Ashley Smith initiated the initial visit with Administrator Yuliya Asatryan. LPA Smith reviewed files at 9:00 a.m., interviewed staff at 8:34 a.m., 9:39 a.m., and 10:03 a.m.

Allegation: Resident sustained a bruise while in care

It was alleged that the responsible party observed R1 to have a bruise on their left hand. A review of medical documents did not display concern or evidence that staff neglected the resident and/or caused R1 to sustain a bruise. The allegation stated that the responsible party observed a bruise; however, the alleged responsible party is actually the complainant and not R1’s responsible party. Interviews confirmed that R1 had sustained a quarter sized bruise on their hand from accidentally hitting the bedrail on R1’s bed.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20220301110139

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: 10/11/2022

NARRATIVE

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Staff interviews revealed that R1 has sensitive skin and had previously unknowingly hit the edge of the bedrail during a transfer. R1 was unable to confirm the source of the bruising. However, staff concluded that R1 sustained this injury on the bed rail when being repositioned. Staff interviews confirmed that R1 was also on blood thinners which caused sensitivity to bruising. The medical records review did not display concern in regard to bruising. Therefore, there is insufficient evidence to support the claim that R1 sustained a bruise while in care due to staff negligence. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility does not meet resident’s nutritional needs

Regarding allegation that the facility does not meet the resident’s nutritional needs. It was alleged that R1 was not being fed and was being served cold food and cereal twice a day. Based on observation the LPA inspected food supply during the visit on 3/2/2022, which demonstrated a variety of foods from all food groups. LPA additionally observed that R1 was being fed during multiple visits unrelated to this complaint and being provided a nutritional array of options. Interviews were conducted with residents regarding food service who stated that they are happy with the quality and quantity of food served at the facility and that staff are very caring and considerate and will prepare foods that are requested and preferred by the residents. LPA reviewed R1’s physicians report and there was no mention of recent weight loss. Therefore, based on the information obtained during this investigation, there is insufficient evidence to support the above allegation that facility failed to provide adequate nutrition to resident, therefore this allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation: Staff spoke inappropriately in the presence of resident.
It was alleged that the facility staff spoke inappropriately in the presence of resident. Information obtained from interviews revealed that on 2/24/2022, facility staff called 911. Complainant claimed that when the ambulance arrived to pick up R1 the Administrator made inappropriate comments in front of the resident. Inconsistent statements were received regarding the interaction between the complainant and the Administrator. Whereas it was alleged that the Administrator was yelling in front of the resident, witnesses to the incident made claims that the complainant was not present or on the property on 2/24/22. The administrator was on the phone with R1's conservator. Based on the information obtained, whereas the Administrator admitted to setting firm boundaries with R1’s visitor in previous interactions there is insufficient evidence to support the claim, that the facility staff spoke inappropriately in the presence of the resident during the incident on 2/24/2022. This allegation is deemed UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20220301110139

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: 10/11/2022

NARRATIVE

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Regarding the allegation: Staff do not assist resident with ambulation
It was alleged that staff do not assist the resident with ambulating. The complainant believed that the staff leaves R1 stuck in a wheelchair or in bed. LPA observation negate claims that staff do not ambulate resident. During multiple visits at the facility the LPA’s observed staff assisting R1 with ambulation. R1 was not observed to be confined to a bed or wheelchair. Based on R1’s physician report R1 is non-ambulatory. Staff interviews revealed that R1 is transported from their bed every morning. Staff claimed that they were following R1’s wishes to lay down when R1 made claims of being tired. Staff stated that R1 would fall asleep at the dinner table or armchair, which could also be interpreted as inappropriate. However, staff indicated that as soon as R1 demonstrated to be tired R1 was placed in bed. Based on the information obtained, there is insufficient evidence to support the claim, that the facility staff do not assist the resident with ambulation. This allegation is deemed UNSUBSTANTIATED at this time.
This allegation was previously addressed in complaint 29-AS-20211124165217

Regarding the allegation: Staff did not seek medical care for resident
Regarding allegation that staff did not seek medical care for the resident. It was alleged that R1 had sustained a bruise on their left hand and staff did not seek medical care for R1’s bruise. Interviews confirmed that R1 had sustained a quarter sized bruise on their hand on 2/20/2022 accidentally hitting the bedrail on R1’s bed. The administrator contacted R1’s primary care physician on 2/20/2022. Staff confirmed that R1 was observed consistently for any changes in condition to hand. Medical record review did not display concern in regard to bruising. Complainant additionally alleged that R1 screams from neck, back and leg pain and has scales on toes and toenails and staff did not seek medical attention. R1 was seen by a podiatrist on a regular basis. Staff interviews confirmed that R1’s feet were very well taken care of. Medical record review did not display concern or evidence of alleged pain or scales on R1’s feet. Medical record review did confirm that R1 has a diagnosis of psychosis with recent episodes of agitation and constant screaming. Therefore, there is insufficient evidence to support that staff did not seek medical care for the resident. This allegation is deemed UNSUBSTANTIATED at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC9099 (FAS) - (06/04)

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