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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606838
Report Date: 02/02/2024
Date Signed: 02/13/2024 11:12:50 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
01/10/2024 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20240110162135
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: DATE:
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 pressure injuries while in care.
INVESTIGATION FINDINGS:
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This is an Amendment to the original report issued 02/02/2024. Additional information was added to clarify the investigation.
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 01/10/2024, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation, “Resident sustained pressure injuries while in care.”
On 01/17/2024, 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), Admission Agreement (dated 09/18/2022), Appraisal Needs and Services (dated 05/01/2023) and Facility Policies and Procedures (Assessment and Retention). During the visit LPA was informed that R1 was receiving Physical Therapy. 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 4
Control Number 31-AS-20240110162135
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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However, R1's file was not available and or missing and LPA was unable to confirm the name and contact information of the agency, frequency of the visits conducted, services provided, etc. LPA also conducted interviews with the Administrator, one (1) out of two (2) staff members and two (2) out of four (4) residents who were able to communicate. On 01/24/2024, LPA Panushkina Subpoenaed R1’s Medical Records. LPA received all requested Medical Records on 01/31/2024.

Allegation: Resident sustained pressure injuries while in care

The investigation findings revealed that Resident #1 (R1) had been living at this facility since September 18th, 2023. Interview with the Administrator revealed that R1 was in bed, most of the time, and the facility staff would reposition R1 every 2 hours. Administrator informed LPA that R1 didn’t like to lay on a side and would always turn to his/her back. Interview with the Administrator also revealed that he was not aware of R1 having any pressure injuries until R1 was taken to the hospital on 01/09/24. Moreover, interviews with two (2) staff members confirmed that R1 had been repositioned every two (2) hours while living at the facility. Both staff members also informed LPA that no pressure injuries were observed on R1’s body. In addition, interview with S2 revealed that he/she provided bed-bath to R1 every day and on 01/09/24, right before R1 was taken to the hospital, S2 noticed a redness around R1’s coccyx area. Review of R1’s Medical Records revealed that R1 was admitted to the hospital (1st time) on 12/22/23 and got discharged on 12/26/23. “Summary of Patient Progress” notes revealed that no skin injury was noted on R1 until 12/25/23 at 2:48pm. As for the type and location it was described as: blanchable redness on buttocks/sacrum/coccyx. Prior to re-admitting R1 back to the facility, facility staff failed to do a re-assessment for R1 prior to discharge on 12/26/23. Therefore, the Administrator failed to get R1 on Hospice, Home Health or obtain a Wound Specialist to address this issue. Subsequently, on 01/09/24, R1 was re-admitted to the hospital, and a review of hospital records revealed that R1 had multiple pressure injuries, from redness, various stage three (3) open injuries and one unstageable injury were discovered.Based on the information gathered, there is sufficient evidence to conclude that the above allegation is 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: 2 of 4
Control Number 31-AS-20240110162135
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(a)(1)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange... for medical and dental care appropriate to the conditions and needs of residents.
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 interview and record reviews, licensee did not comply with the section cited above by providing care to R1 without hiring a Wound Specialist and or a medical professional from 12/26/23 to 01/09/24, which poses/posed an immediate health and safety risk to resident in care.
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This is a zero tolarance and an immediate civil penalty of $500.00 will be assessed
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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: 3 of 4
Control Number 31-AS-20240110162135
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 B
02/09/2024
Section Cited
CCR
87463(a)
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Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical...
This requirement is not met as evidenced by:
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Administrator agreed to submit a statement of understanding on how all residents will have a proper reappraisal when changes occur and coming out of the hospital to ensure their needs are met. Proof of statement shall be submitted to LPA by POC date.
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Based on interview and record reviews, licensee did not comply with the section cited above. Adminsitrator confirmed that upon R1's discharge from the hospital on 12/26/23, R1's reappraisal was not updated, which poses/posed a potential health and safety risk to resident 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: 4 of 4