197605522-12-29-2021-29-AS-JAPL-CB9SJU-20220202125539

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 12/29/2021
Date Signed: 12/29/2021 02:40:58 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
12/22/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20211222164137

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:	12/29/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Yulia Asatryan and Francisca Recede		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not notify conservator of residents change in condition

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos arrived unannounced to conduct an initial 10-day visit. The LPAs met with Yulia Asatryan and Francisca Recede and explained the reason for the visit. During today’s visit, the LPAs interviewed staff, reviewed documents, and spoke with the conservator of Resident #1 (R1).

Regarding the above allegation, it was alleged that the facility failed to report unusual incidents pertaining to R1 to R1’s conservator. Interviews revealed that on or approximately on 12/23/2021, a case worker observed R1 in this facility and it was reported that R1 had two prior episodes of bloody discharge. Interviews with R1’s conservator confirmed that R1’s conservator was unaware of these incidents and claimed that they were notified by the case worker, and not the facility staff. Staff interviews revealed that whereas R1 had experienced bloody discharge, they notified R1’s primary care physician to ensure a timely response and treatment.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

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 3

Control Number 29-AS-20211222164137

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: 12/29/2021

NARRATIVE

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Staff claimed that when the staff observed the bloody discharge, it was reported to the Administrators. The LPAs could not find documentation supporting the date(s) as to when staff observed the bloody discharge. Records demonstrated that on 12/20/2021, R1's doctor came to the facility due to bloody discharge. The conservator nor the case worker were aware of any bloody discharge until 12/23/2021. Staff admitted to not speaking to R1’s conservator directly and felt that informing the case worker of the incident was sufficient, as they would relay the information to the conservator.

Based on the information obtained, there is sufficient evidence to support the claim that staff did not notify conservator of residents change in condition. This allegation is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit Interview Conducted. Appeal Rights and a copy of this report has been issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20211222164137

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: 12/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/03/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident. ... When changes such as ... a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Document a Plan of Action, detailing the steps the facility will take to ensure that they maintain compliance with Regulation 87466. Submit Plan of Action to CCL by 1/3/2022.
	8 9 10 11 12 13 14	Based on interview, the licensee did not comply with the section cited above, as staff failed to report an incident to R1’s conservator, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

LIC9099 (FAS) - (06/04)

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