197605522-2-2-2023-29-AS-JAPL-CP437P-20230215170016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:31:49 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
11/24/2021 and conducted by Evaluator Christine Yee

COMPLAINT CONTROL NUMBER: 29-AS-20211124165217

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: 5	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Yuliya Asatryan, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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1. Staff left resident in soiled diaper for extended period of time
3. Facility has mold
4. Staff are not meeting resident's hygiene needs
5. Staff left resident in wheel chair sleeping
6. Staff did not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Christine Yee conducted a subsequent unannounced complaint visit to conduct further investigation of the above allegations and was let into the home by Florencio Aguilon, Staff. Yuliya Asatryan, Administrator was contacted by staff and arrivied a little later to conduct the visit.. LPA Yee explained the reason for today's visit.

An initial unannounced complaint visit was conducted by LPAs Teresa Camara and Elsie Campos on 12/1/22. LPAs met with Francisca Recede. They conducted a facility tour at 10:35 a.m. LPAs conducted interviews with administrator at 10:56 a.m., resident at 10:26 a.m., and 12:36 a.m. with staff. LPAs reviewed and obtained pertinent records

continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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-20211124165217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A HEAVENLY HAVEN, INC.	FACILITY NUMBER: 197605522
	VISIT DATE: 02/02/2023

NARRATIVE

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at 11:42 a.m. During this visit, LPAs observed that the facility carpets had been removed and replaced in the hallways, living room, family room, dining room and bedrooms. LPAs also observed large gaps in portions where the flooring is still being installed and construction trash in the backyard. LPAs Camara and Campos determined that allegation #2 - the floors are in disrepair to be substantiated. The facility was cited and a plan of correction was given to correct the deficiency.

On today's visit, LPA Yee conducted additional interviews with Staff #1 and Yuliya Asatryan from 10:06 am through 11:50am, toured the physical plant at 11:50am - 12:05pm, reviewed and obtained copies of facility records related to the above allegations at 12:21pm. The following information was obtained for each allegation:

Allegation #1 - Staff left resident in soiled diaper for extended period of time. Per interviews conducted, staff check residents every two hours or the residents who are alert will tell them if they need to be changed or they will pull the alarm. Per Staff #1 and the Administrator, they pay special attention to Resident #1 and would check the resident regularly due to having very sensitive skin. Resident #1 would break out in rashes if not changed immediately. New staff are advised of resident #1's sensitive skin and the need to change soiled diaper immediately. Residents are not left in soiled diapers.

Allegation #3 - the facility has mold. A tour of the entire facility, inside and outside, was conducted from 11:50am - 12:05pm. The facility is located in a very nice and quiet neighborhood. Per tour of the facility, it was observed that the facility was very clean and well maintained including the ceiling in the front living room where it was alleged that the mold was observed. There were no molds observed anyway in the facility. Tiny black spots observed around the air vent located on the ceiling could be mistaken for mold but upon close inspection, are actually tiny cracks or holes in the plaster surrounding the air vent. During the tour LPA Yee also observed that all the windows had lace curtains and solid drapes including the window closes to the kitchen. The kitchen is located in the center of the house has no outside windows.

continued on LIC9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211124165217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A HEAVENLY HAVEN, INC.	FACILITY NUMBER: 197605522
	VISIT DATE: 02/02/2023

NARRATIVE

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Allegation #4 - Staff are not meeting resident's hygiene. At 1:45pm Staff #1 and Staff # 2 were interviewed regarding the residents daily bathing schedules. Per information provided, staff give the residents daily sponge baths and brush the residents' teeth or clean dentures on the dates that home health or hospice nurse are not scheduled for visits. The sponge baths are given in the mornings and hair is washed once or twice a week. Staff will also clean the residents nails as needed. It is alleged that Resident #1 is observed with poop under her nails. Per staff, Resident #1 loves chocolates and would get chocolate under her nails and needs her nails cleaned afterwards. Resident #1's arms are stiff and is unable to reach own back or reach below the waist to get hands dirty.

Allegation #5 - staff left resident in wheel chair sleeping. Per staff, Resident #1's daughter visits in the evening and likes to see Resident#1 dressed and waiting in the wheel chair set up by the breakfast table. Staff keep Resident #1 company until the daughter comes to visit. Resident #1 does not fall asleep but closes eyes while waiting for the daughter to arrive. The daughter will also call and talk for a long time even when Resident #1 is already in bed.

Allegation #6 - staff did not safeguard resident's belongings. Per review of facility records, a completed LIC 621 Client/Resident Personal Property and Valuables was observed in Resident #1's file. Per staff, Resident #1's daughters are feuding and are not on good terms and do not communicate with each other. Daughter #1 would take the resident's clothing home and Daughter #2 would blame the facility for losing Resident #1's clothing. Resident #1 had a ring when admitted to the facility and when the resident's spouse and family were visiting, the ring was removed and given to the resident's spouse. Resident #1 was also observed with a single stud earring and it was removed and given to Daughter #2, who wanted it for sentimental value. Daughter #2 signed for the earring. On both occasions, Daughter #1 blamed the facility for not safeguarding the resident's belonging.

Based on the information obtained during the investigation, all the above allegations are unsubstantiated. Exit interview was conducted with Florencio "Augie" Aguilon and a copy of the report given.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

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