197606861-1-24-2022-31-AS-CHAS-CBJURN-20220211144900

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606861
Report Date: 01/24/2022
Date Signed: 01/24/2022 02:17:30 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2020 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20201217131724

FACILITY NAME:	WEST HILLS CARE HOME		FACILITY NUMBER:	197606861
ADMINISTRATOR:	ELAINE BOTE		FACILITY TYPE:	740
ADDRESS:	22956 INGOMAR STREET		TELEPHONE:	(818) 888-9573
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91304
CAPACITY:	6	CENSUS: 3	DATE:	01/24/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Edelina Igaya		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident sustained a fall while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit.
LPA spoke with the administrator by telephone and explained the reason for this visit.
Regarding the allegation above it above it is alleged that resident #1 (R1) sustained a fall due to facility negligence. Previous visits were conducted on 12/24/2020 and 5/19/2021. During today's visit LPA conducted interviews with R1's responsible person from 9:30am to approximately 10am. LPA reviewed R1's facility file including hospice documentation from 10-11:30am. LPA conducted interviews with facility staff from 11:30-12pm regarding the allegation. Information obtained from interviews reveal that on 2/29/2020 R1 was receiving assistance from Kumar hospice staff when they had a fall in the backyard of the facility. Facility staff saw the accident and went to assist R1 up. Facility staff contacted the administrator and the Hospice complany and let them know about the fall. The administrator spoke with Kumar Hospice and R1's responsible person regarding the fall. Kumar Hospice stated that R1 was fine and they would monitor R1 over the next couple of days. The next day facility staff called Hospice and reported that

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20201217131724

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: WEST HILLS CARE HOME	FACILITY NUMBER: 197606861
	VISIT DATE: 01/24/2022

NARRATIVE

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R1 was in pain. Kumar Hospice agency reported to R1's responsible person that they would arrange for x-rays to be taken of R1 at the facility. A review of R1's hospice records indicate that they were seen by Hospice on 3/1/2020 and 3/2/2020 and the fall was noted and that R1 had complained of pain, but that R1 had refused to go the hospital to be seen by a physician. On 3/3/2020 a x-ray was taken of R1's leg and it was found there was a fracture and R1 was then taken to the hospital. Based on the information obtained through interviews with facility staff, R1's responsible person, and a review of R1's facility file and medical records this allegation is deemed Unsubstantiated at this time. R1's fall happened under the supervision of Kumar Life Hospice staff and the facility staff alerted Kumar Hospice and R1's responsible person regarding the fall. Facility staff also monitored R1 and reported updates regarding R1 to hospice and R1's responsible party.
Exit Interview conducted.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

LIC9099 (FAS) - (06/04)

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