197605522-8-31-2021-29-AS-JAPL-C7HMEX-20211005093321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 08/30/2021
Date Signed: 08/31/2021 10:01:32 AM

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. 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:	08/30/2021
		UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Francisca Recede, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident not administered medication as prescribed.
Facility staff not maintaining residents hygiene.
Call button not accessible to resident.
Resident provided with dirty drinking water.
Facility staff does not check temperature prior to entering the facility.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Salia Walker conducted a subsequent complaint investigation visit on 08/31/21 between 09:01 a.m. and 10:00 a.m. Due to a computer error, the LPA was unable to issue the additional LIC 9099A during the initial visit on 08/30/21 for the above allegations. This is an updated report to include the additional form LIC9099A. The LPA was initially greeted by staff, and later met with Administrator Francisca Recede at 10:44 a.m. and explained the reason for the visit.

During initial visit on 08/30/21, the LPA conducted a physical plant tour at 10:16 a.m. Between 11:46 a.m. and 11:59 a.m., the LPA conducted interviews with two (2) out of four (4) residents. Between 10:28 a.m. and 10:32 a.m., the LPA conducted an interview with one (1) staff. Between 10:49 a.m. and 11:46 a.m., the LPA conducted an interview with the Administrator. The LPA reviewed records between 10:32 a.m. and 10:49 a.m., and obtained copies of records pertinent to the investigation. Between 11:59 a.m. and 12:30 p.m., the LPA conducted a medication review.

Continued on LIC 9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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 4

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: 08/30/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation, ‘Resident not assisted with medication as prescribed’, the complainant’s concerns is that they believe that resident #1 (R1) is constantly tired from R1’s medication, and is concerned that it is due to R1 being over medicated. LPA Walker conducted a medication review to determine if staff assisted with R1’s medication as prescribed. The LPA found that the medication count matched the number of pills remaining. Staff also confirmed that they assist with medication as it is prescribed. Based on the medication review, interviews, and record review for R1, there was no evidence found that R1 was not assisted with their medication as prescribed. Therefore, this allegation is deemed Unsubstantiated at this time.

Regarding the allegation, ‘Facility staff not maintaining resident’s hygiene’, the complainant alleged that during a visit to the facility, R1 was observed with dirty nails. The complainant was concerned that R1’s had excrement under the fingernails. The LPA interviewed R1 and made an observation of R1’s nails and observed that R1’s hygiene is adequate. Staff interviews stated that all residents are bathed once a day. Interview with resident #2 (R2) revealed that residents are bathed once a day.

Based on interviews conducted with residents, staff, administrator, and family members, there was insufficient evidence to confirm the allegation. Therefore, this allegation is deemed Unsubstantiated at this time.

Regarding the allegation, Call button not accessible to resident. The complainant’s concern was that R1 does not have a call button. Upon interviews with staff, and residents, it was revealed that none of the residents have a call button at the facility. Per Title 22 Regulation 87303(i) Maintenance and Operation: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. Based on facility records review, and physical plant tour, the above facility does not fall under this category for regulation 87303(i)(1)(B) due to it being a six (6) bed facility. Therefore, this allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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: 08/30/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation, ‘Resident provided with dirty drinking water’, the complainant alleged one (1) out of two (2) staff gave R1 dirty drinking water. The LPA attempted to obtain additional information regarding what constituted dirty drinking water; however, the complainant was not able to provide any additional information. The LPA observed the water in the facility and found that the facility has a contract with Sparkletts Water which delivers bi-weekly. The LPA observed staff providing water from the filter machine which dispensed the Sparklett water.

Based on observation by the LPA, interviews conducted with staff, residents, and R1’s family members, there is insufficient evidence to conclude this allegation. Therefore, this allegation is deemed Unsubstantiated at this time.

Regarding the allegation, Facility staff does not check temperature prior to entering the facility. The complainant’s concern was that staff do not check visitor’s temperatures upon entry into the facility. During today’s visit, the LPA’s temperature was checked and logged before the LPA was allowed entrance into the facility. Interviews with staff confirmed that all visitor’s temperatures are checked and logged before entry into the facility. Based on documents collected, interviews, and the LPA’s observation, the facility is adhering to screening regulation per CDSS. Therefore, this allegation is deemed Unsubstantiated.

Exit interview conducted, a copy of report issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4