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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606838
Report Date: 02/02/2024
Date Signed: 02/02/2024 11:39:42 AM

Substantiated


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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/05/2023 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20230605162033
FACILITY NAME:TWIN PALMSFACILITY NUMBER:
197606838
ADMINISTRATOR:JOHN MALLONFACILITY TYPE:
740
ADDRESS:19929 SEPTO STREETTELEPHONE:
(818) 773-9291
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 5DATE:
02/02/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amorlina Comedia, Staff TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained a burn in care due to lack of supervision.
Facility staff did not seek timely medical attention for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with Amorlina Comedia, Staff #1 (S1), who granted access to the facility. S1 contacted the Administrator and LPA explained the reason for the visit. Administrator was unable to come to the facility and designated S1 to sign the report.

On 06/05/2023, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegations, “Resident sustained a burn in care due to lack of supervision" and "Facility staff did not seek timely medical attention for resident." The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to investigator Dennis Douglas.

On 06/06/23, LPA Panushkina initiated the complaint. LPA conducted tour of the facility and obtained copies of pertinent information which include but not limited to Physician’s Report (dated 08/24/2022),
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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 5
Control Number 31-AS-20230605162033
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TWIN PALMS
FACILITY NUMBER: 197606838
VISIT DATE: 02/02/2024
NARRATIVE
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Admission Agreement (dated 09/18/2022) and Appraisal Needs and Services (dated 05/01/2023). LPA conducted interviews with Administrator, one (1) out of two (2) staff members and two (2) out of four (4) residents. Investigator Douglas conducted interviews with Medical Social Worker (on 07/19/23), R1, Administrator and two (2) staff members (on 07/28/23). Moreover, on 08/23/23 the Investigator visited “West Hills Hospital Burn Center” and conducted an interview with the Chief Medical Officer and obtained Medical Records for R1. Lastly, the Investigator conducted an interview with a witness on 08/28/23.

Allegation: Resident sustained a burn in care due to lack of supervision

The investigation findings revealed that R1 had been living at this facility since September 18th, 2023. Although, R1 was able to communicate his/her needs and feed self, due to R1’s physical condition, R1 required assistance with the Activities of Daily Living (ADL). On 05/26/23, R1 was in bed, watching TV and facility staff served very hot soup (requested by R1) for lunch. S2 placed the hot soup on the “over the bed” tray/table (on wheels) next to R1’s bed and left the room. No staff made sure that the table was stable and R1 was in a position in which they were able to prevent the spill. When R1 went to grab the soup from the table it spilled on his/her thigh causing the burn. It was revealed that the tray/table was loose causing it to wobble, which contributed to the soup spilling. When R1 called for help, Staff #1 (S1) and Staff #2 (S2) went to R1’s room, placed R1 on a wheelchair and then cleaned the bed. Immediately, after R1 was changed/treated, the facility staff contacted the Administrator and notified of an incident. Administrator instructed them, via telephone, to put ice and ointment (aloe vera) on the wound. After the Administrator arrived to the facility and observed R1’s burn did not appear to be blistering and R1 did not complain of any pain, Administrator determined to wait for a Home Health agency that was already scheduled to come to the facility in the coming days. However, the Home Health agency did not come on their scheduled treatment date and even then, R1 was not taken to the hospital. Since R1 had also already been scheduled to see his/her primary doctor in the coming 5 days, the Administrator made a decision to wait, although by the 2nd or 3rd day, the burn began to blister. On 05/30/23, during the scheduled doctors appointment, the doctor recommended R1 be transferred to the burn center because they did not have a burn unit at that particular Kaiser facility. Once admitted to the hospital (on 05/30/23) R1 was diagnosed with large 2nd/3rd degree burn to his/her left thigh. Interview with the Chief Medical Officer revealed that R1 needed to be hospitalized for 16 days as a “skin graft” was needed to repair the damage done to R1’s thigh as a result of the burns.
Continue on LIC9099-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230605162033
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TWIN PALMS
FACILITY NUMBER: 197606838
VISIT DATE: 02/02/2024
NARRATIVE
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Per the medical report, it was noted that on, 06/01/23, a debridement was performed down to the deep dermal tissue and an application of homograft cadaveric skin to the left thigh.

Allegation: Facility staff did not seek timely medical attention for resident.

On 05/26/23, R1 was in bed, watching TV and the facility staff served very hot soup (requested by R1) for lunch. S2 placed the hot soup on the “over the bed” tray/table (on wheels) next to R1’s bed and left the room. No staff made sure that the table was stable and R1 was in a position in which they were able to prevent the spill. When R1 went to grab the soup from the table it spilled on his/her thigh causing the burn. Immediately, after R1 was changed/treated, the facility staff contacted the Administrator and notified of an incident. Administrator instructed them, via telephone, to put an ice and ointment (aloe vera) on the wound. After the Administrator arrived to the facility and observed R1’s burn did not appear to be blistering and R1 did not complain of any pain, Administrator determined to wait for a Home Health agency that was already scheduled to come to the facility in the coming days. However, the Home Health agency did not come on their scheduled treatment date and even then, R1 was not taken to the hospital. Since R1 had also already been scheduled to see his/her primary doctor in the coming 5 days, the Administrator made a decision to wait, although by the 2nd or 3rd day, the burn began to blister. Even then, the Administrator did not call 9-1-1, instead the facility staff simply treated R1’s injury with over-the-counter ointment for 4 or 5 days. When R1 was ultimately taken to the hospital, R1's wound was classified as a 2nd or 3rd degree burn to 4% of R1's body.

Based on the information gathered, there is sufficient evidence to conclude that the above allegations are Substantiated.

A $500 immediate civil penalty is assessed today for a violation resulting R1's serious bodily injury. The Licensee/Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f).

Deficiencies/civil penalty were issued per CA code of Regulations Title 22 on LIC-9099D
Exit interview conducted, appeal rights explained and a copy of this report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20230605162033
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TWIN PALMS
FACILITY NUMBER: 197606838
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2024
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health....
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening again and to ensure compliance to the cited regulation
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Based on the investigation, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, which poses/posed an immediate health and safety risk to residents in care.
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This is a zero tolarance and an immediate civil penalty of $500.00 will be assessed
Type A
02/03/2024
Section Cited
CCR
87411(d)(5)
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87411(d)(5) Personnel Requirements – General: (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following... (5) Knowledge necessary in order to recognize... the need for professional help.
This requirement is not met as evidenced by:
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Licensee agreed that all personnel (current and or future) will receive the required training. A verification of staff training will be submitted to CCLD by POC date.
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Based on the investigation, the licensee did not comply with the section cited above, as the facility staff walked away and left a hot soup on an unstable table and failed to provide an appropriate supervision. Although, the staff was trained with all the required basic services, the staff did not immediately call 911. Instead, they contacted the Administrator who made a decision to wait for R1’s doctors appointment that was already scheduled on a 05/30/23 (5 days after the incident), which poses/posed an immediate 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230605162033
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TWIN PALMS
FACILITY NUMBER: 197606838
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2024
Section Cited
CCR
87405(b)
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87405(b) Administrator - Qualifications and Duties: (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.
This requirement is not met as evidenced by:
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Licensee agreed that the facility Administrator, designee and all staff will be trained on 911 situations and emergency step-by-step procedure for the residents. Proof of training will be submitted to CCLD by POC date.

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Based on the investigation, the Administrator did not comply with the section cited above, failing to follow and carry out an emergency policy, which poses/posed an immediate 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5