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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 02/02/2022
Date Signed: 02/02/2022 04:12:53 PM



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
11/03/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211103162557
FACILITY NAME:A HEAVENLY HAVEN, INC.FACILITY NUMBER:
197605522
ADMINISTRATOR:FRANCISCA M. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
02/02/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Aguilon 'Agi' FlorencioTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff are not enforcing visitors to wear masks.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent visit to deliver the findings for the above allegation. The LPA met with staff Aguilon 'Agi' Florencio and explained the reason for the visit. The LPA called Administrator Francisca Recede over the phone and informed them of the findings. Ms. Recede authorized staff to sign the report.

During an initial visit conducted on 11/09/2021, the LPA conducted a tour at 11:15 a.m., reviewed files at 11:25 a.m., interviewed staff at 11:45 a.m., 12:36 p.m., and 12:50 p.m., and attempted to interview residents at 12:58 p.m. and 2:15 p.m. The LPA also interviewed home health representatives at 12:09 p.m. and 3:00 p.m. A medication audit was conducted at 2:20 p.m.

On 1/03/2022, the LPAs conducted a medication audit at 11:30 a.m., interviewed Resident #1 (R1) at 11:40 a.m., completed a tour at 11:50 a.m., reviewed documents, interviewed staff at 12:00 p.m., and interviewed the responsible parties of four (4) residents at 12:45 p.m., 2:33 p.m., 2:49 p.m., 3:08 p.m., and 3:44 p.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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 7
Control Number 29-AS-20211103162557
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: 02/02/2022
NARRATIVE
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Regarding the allegation: Staff are not enforcing visitors to wear masks.
It was alleged that on 11/03/2021, visitors came into the facility and were improperly wearing a face mask. During the LPA’s visit, the LPA observed staff and incoming visitors wearing masks at all times. Interviews with frequent visitors supported claims that staff enforce visitors to wear masks throughout the duration of their stay at the facility. A similar allegation was made in complaint control # 29-AS-20210825165202, and the allegation was Substantiated on 09/22/2021 following the investigation as facility staff were observed removing their mask on various occasions throughout the visit. Whereas this behavioral pattern was not observed in future visits, additional evidence was submitted from 11/03/2021, where a photograph was produced of a visitor improperly wearing a surgical mask on their chin. At the time of observation, the visitor was close to R1, and it was unknown at that time if the visitor was vaccinated. Concern was raised as the visitor was improperly wearing a mask in close proximity of R1, whom was unvaccinated.

Based on the investigation, there is sufficient evidence to support the claim that staff are not enforcing visitors to wear masks. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, a copy of the report and appeal rights were provided

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20211103162557
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2022
Section Cited
CCR
87467(f)(2)
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87467 (f)(2) Basic Services. Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Reinforce the visitation policies and procedures with staff, specifically highlighting the mask-wearing policy. Inform the LPA when this has taken place, but no later than 2/11/2022.
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Based on evidence obtained, the licensee did not comply with the section cited above, as one visitor was observed without their mask as required, which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
11/03/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211103162557

FACILITY NAME:A HEAVENLY HAVEN, INC.FACILITY NUMBER:
197605522
ADMINISTRATOR:FRANCISCA M. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
02/02/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Aguilon 'Agi' FlorencioTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Resident not administered medication as prescribed.
Resident not awarded privacy.
Staff is limiting resident phone calls
Staff are administering COVID-19 vaccines.
Staff is not following resident's wheelchair care plan.
Staff are not enforcing temperature checks for visitors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent visit to deliver the findings for the above allegation. The LPA met with staff Aguilon 'Agi' Florencio and explained the reason for the visit. The LPA called Administrator Francisca Recede over the phone and informed them of the findings. Ms Recede authorized staff to sign the report.

During an initial visit conducted on 11/09/2021, the LPA conducted a tour at 11:15 a.m., reviewed files at 11:25 a.m., interviewed staff at 11:45 a.m., 12:36 p.m., and 12:50 p.m., and attempted to interview residents at 12:58 p.m. and 2:15 p.m. The LPA also interviewed home health representatives at 12:09 p.m. and 3:00 p.m. A medication audit was conducted at 2:20 p.m.

On 1/03/2022, the LPAs conducted a medication audit at 11:30 a.m., interviewed Resident #1 (R1) at 11:40 a.m., completed a tour at 11:50 a.m., reviewed documents, interviewed staff at 12:00 p.m., and interviewed the responsible parties of four (4) residents at 12:45 p.m., 2:33 p.m., 2:49 p.m., 3:08 p.m., and 3:44 p.m.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20211103162557
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: 02/02/2022
NARRATIVE
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Regarding the allegation: Resident not administered medication as prescribed.
It was alleged that staff were not assisting R1 with the self-administration of medications appropriately. Between the visits conducted on 11/9/2021 and 1/03/2022, the LPA conducted a medication audit for four out of four residents. The LPA did not identify any medication errors during the medication audit. The LPA reviewed the file for R1 and was unable to identify any medication changes or adjustments. Staff interviews revealed that they administered medications to all residents in a timely manner and did not communicate any known medication errors. A similar allegation was made in complaint control # 29-AS-20210825165202, and the allegation was Unsubstantiated on 08/30/2021 following the investigation. Based on the information obtained, there is insufficient evidence to support the claim that R1 was not assisted with the self-administration of medication as prescribed. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident not awarded privacy
It was alleged that R1 was not allowed privacy in their visits and noted that their visits were always interrupted. Interviews revealed that oftentimes, R1 would have visitors in common spaces in the facility. Interviews also revealed that R1’s visitors would oftentimes arrive around dinnertime, in which R1 was present at the dining table, thus the visit would be held at the dining room table. Staff interviews revealed that they had not made claims to R1 or to R1’s visitors that they were unable to have visits in R1’s room or other areas in the facility yet had a designated visitor’s area due to COVID-19. Interviews with additional responsible parties of other residents denied claims that their visits had ever been interrupted and stated that staff always respected their privacy when visiting residents in the facility. An interview conducted with a resident whom resided in the facility supported claims that they were able to have private visits and felt that their visits were never intentionally interrupted. Inconsistent statements were shared regarding interactions that R1’s visitors have had with staff during visits. Whereas claims are made that R1’s visitor feels harassed by the staff during visits, staff have made similar claims in regard to how R1’s visitor treats the staff. Notably, interviews with additional responsible parties denied claims that they have ever felt harassed by the staff. Based on the information obtained, there is insufficient evidence to support the claim that R1 was not allowed privacy. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff is limiting resident phone calls
It was alleged that incoming calls to R1 are limited. Interviews with staff revealed that R1 receives regular phone calls from two family members.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20211103162557
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: 02/02/2022
NARRATIVE
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 It was alleged that whereas one family member calls to check in on R1’s progress and talks with R1 for a reasonable amount of time, one of R1’s family members will call and attempt to stay on the phone with R1 for ‘more than an hour’, to the point where other calls cannot come through. Staff mentioned that R1 is unable to hold the phone, so staff must put the phone on speaker for R1 to hear their callers. Staff claimed that they allow R1 to stay on the phone as long as they desire. Staff denied claims that they decline incoming calls from R1’s family members and claim that they will receive calls from the responsible parties of other residents when they are unable to get through on the facility line. Interviews with additional responsible parties of other residents denied claims that phone calls had ever been limited or interrupted and stated that staff always allowed for them to call their loved ones in the facility. Based on the information obtained, there is insufficient evidence to support the claim that staff were limiting R1’s phone calls. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff are administering COVID-19 vaccines.
It was alleged that unqualified staff were administering COVID-19 vaccines. The complainant was concerned that unvaccinated ‘strangers’ were coming into the facility to receive vaccine dosages, and were inadvertently exposing R1. Interviews and record review confirmed that on 11/03/2021, the facility contracted with a home health agency to receive COVID-19 booster dosages. Furthermore, the investigation revealed that the COVID-19 booster was provided to staff that were fingerprint cleared and associated to work at this facility and the licensee’s other facility, A Heavenly Haven, Inc II (Facility Number 197606737). The LPA interviewed the registered nurse whom administered the booster dosages, and they sent over the certification forms for all whom received the booster that day. In addition, one of the residents received the COVID-19 booster shot.

Based on the investigation, there is insufficient evidence to support the above-mentioned claim. The individuals receiving the vaccine were associated to this facility and the licensee’s other facility. The COVID-19 booster shots were administered by an appropriately skilled professional, and those coming in the facility for the booster were vaccinated against COVID-19. This allegation is deemed Unsubstantiated at this time.



Regarding the allegation: Staff is not following resident's wheelchair care plan.
It was alleged that staff fail to properly position R1 in their wheelchair, noting that R1’s feet are always left dangling and not resting on the wheelchair’s footrest. Throughout the investigation, the LPA made several visits to this facility. On all occasions, staff have had to assist R1 with transferring to their wheelchair.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20211103162557
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: 02/02/2022
NARRATIVE
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At all times, the LPA observed staff closely monitoring R1 as they are pushing R1 in the wheelchair, and the footrest is always engaged. Staff interviews revealed that the only time that the footrest is disengaged is when R1 is eating, as it allows R1’s wheelchair to get closer to the table and staff can better assist R1 with feeding. Staff denied claims of R1 ever exhibiting any pain or discomfort when the footrests are temporarily disengaged while eating. Staff noted that they have communicated this to R1’s conservator, whom communicated no concern. Lastly, there is no documented care plan as it relates to the use of R1’s wheelchair. Based on the investigation, there is insufficient evidence to support the claim that staff failed to follow R1’s wheelchair care plan. This allegation is deemed Unsubstantiated at this time.


Regarding the allegation: Staff are not enforcing temperature checks for visitors.
It was alleged that staff fail to check the temperatures of visitors entering the facility, particularly those whom entered the facility on 11/3/2021 for the COVID-19 boosters. Interviews conducted with the home health nurse whom administered the dosages on 11/3/2021 stated that upon entry into this facility, their temperature was checked. The staff responsible for checking temperatures corroborated the claim that they checked the temperatures of those who entered the facility. Interviews with visiting home health aides, and interviews with additional responsible parties of other residents whom visit often confirmed that staff are diligent about checking and documenting their temperatures upon entry into the facility. Lastly, throughout the investigation, the LPA made several visits to this facility. The staff at this facility have consistently made sure to check and log the LPA’s temperature before entry into this facility. Based on the investigation, there is insufficient evidence to support the claim that staff are not enforcing temperature checks for visitors. 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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7