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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607173
Report Date: 12/18/2021
Date Signed: 12/18/2021 04:01:44 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
03/15/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210315092346
FACILITY NAME:WEST HILLS HOME CARE IIFACILITY NUMBER:
197607173
ADMINISTRATOR:MYLENE C. CARREONFACILITY TYPE:
740
ADDRESS:22454 SCHOOLCRAFT STREETTELEPHONE:
(818) 610-7276
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:0CENSUS: 5DATE:
12/18/2021
UNANNOUNCEDTIME BEGAN:
03:23 PM
MET WITH:Joanne GatelaTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Licensee failed to obtain timely medical care for Resident 1 (R1)
Licensee retained resident 1 (R1) with a prohibited health condition.
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. This investigation was conducted by Douglas Real, Investigator with Community Care Licensing Division’s Investigations Branch.
During the course of the investigation, Investigator Real conducted interview with various individuals including the licensee/administrator, facility staff, Resident 1 (R1’s) family/responsible party. On 3/15/2021 during the initial 10 day complaint visit LPA Avetisyan conducted interviews with the Licensee/administrator. On 4/15/2021 Investigator Real received and reviewed R1’s medical records from Kaiser Permanente.

Regarding the allegations it was reported that on 3/11/2021 resident 1 (R1) was seen at Kaiser wound care clinic for a stage 3 pressure injury on her left foot. According to complainant the wound developed on 1/21/2021 and the delay in medical care cause the wound to become a stage 3.

Information obtained from the interviews conducted and records reviewed revealed the following: Staff 1 (S1) recalled seeing redness develop on R1’s foot sometime in January 2021. S1 as well as the licensee
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021
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 4
Control Number 31-AS-20210315092346
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 HOME CARE II
FACILITY NUMBER: 197607173
VISIT DATE: 12/18/2021
NARRATIVE
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administrator provided wound care to R1. This is prohibited, as wound care should only be provided by an appropriately skilled professional. The redness developed into a blister sometime in February 2021. R1 was taken to the doctor after the blister opened in March 2021. On 6/2/2021 when interviewed the licensee/administrator reported notifying R1’s daughter/ Power of Attorney (POA) when the redness was observed, however failed to notify R1’s physician. According to the licensee /administrator she asked for R1 to be taken to the doctor, however the POA failed to do so. On 6/22/2021 Investigator real interviewed R1’s POA who confirmed being notified of the pressure injury and not taking contacting the physician or taking R1 to see the physician after the wound worsened.

Review of the medical records revealed the following: On 3/1/2021 R1’s POA contacted Kaiser physician via email and reported the pressure injury as a lesion and indicating facility staff have been treating the pressure injury/lesion. R1’s POA also sent photos of the pressure injury attached to the email. On 3/2/2021 the physician responded by writing “that does not look good” and notifying the POA that he will be completing a referral for the wound clinic. The physician also wrote that R1 be taken to urgent care for evaluation if the wound worsens.


On 3/11/2021 R1 was seen at Center for Wound Healing at which time the wound was diagnosed as a stage 3 pressure injury. After the diagnosis Kaiser staff contacted the licensee/administrator who requested that R1 be enrolled in hospice care until the pressure injury healed. Kaiser staff also documented that Licensee/administrator was “comfortable allowing R1 to return to the facility, pending assessment of possible hospice care”. Hospice referral was closed due to R1 not having a terminal diagnosis on 3/12/2021.
Information obtained during the course of the investigation revealed the following: R1 developed a pressure injury January 2021, licensee/administrator did not obtain timely medical care until March 2021. From January to March 2021 the facility staff who are not skilled medical professionals provided wound care. R1’s pressure injury worsened and when R1 was seen by wound specialist the pressure injury was diagnosed as a stage 3 which is a prohibited health condition. Because of the information obtained the allegations are Substantiated.

This licensee/administrator is no longer operating this facility due to the department taking administrative actions. This report was delivered Home Care of West Hills # 1 LLC facility # 197610149. During the visit LPA spoke with the current licensee/administrator Stephanie Hilado via telephone. Ms Hilado attempted to contacted the prior licensee/administrator Mylene Carreon but was unable to do so. Ms. Hilado designated staff Joanne Gatela to sign for the report and indicated that she will follow up with Ms. Carreon.

Exit interview conducted, copy of report citations , civil penalties and appeal rights emailed to MYLENE_CARREON@YAHOO.COM and HILADO_STEPHANIE@YAHOO.COM

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20210315092346
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 HOME CARE II
FACILITY NUMBER: 197607173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2021
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the residents RP
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The prior licensee/administrator Mylene Carreon will submit a detailed written explanation why she failed to notify the residents physician when the pressure injury was observed, why she failed to obtain medical care for the pressure injury, and why she re-admitted/retained R1 when the pressure injury was diagnosed as a stage 3.
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This requirement was not met as evidenced by: Based on information obtained during the investigation, the licensee/administrator did not comply with the cited section by not notifying the physician when noticeable changes were observed in R1’s condition which posed an immediate health, safety and personal rights risk to R1.
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A civil penalty in the amount of $500 has been issued due the violation of the residents health and safety while in care.
Type A
12/20/2021
Section Cited
CCR
87631(a)(3)(A
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Except as specified in Section 87611(a), the licensee shall be permitted to
accept or retain a resident who has a healing wound under the following circumstances:
(A)The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional. This Requirement was not met as evidenced by:
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The prior licensee/administrator Mylene Carreon will submit a detailed written explanation why she failed to notify the residents physician when the pressure injury was observed, why she failed to obtain medical care for the pressure injury, and why she re-admitted/retained R1 when the pressure injury was diagnosed as a stage 3.
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Based on information obtained during the investigation, the licensee/administrator did not comply with the cited section by not having R1’s pressure injury diagnosed and be cared for by a physician or an appropriately skilled medical professional which posed an immediate health, safety and personal rights risk to R1.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 31-AS-20210315092346
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 HOME CARE II
FACILITY NUMBER: 197607173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2021
Section Cited
CCR
87615(a)(1)
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Persons who require health services for or have a health condition including, but not
limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This Requirement was not met as evidenced by:
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The prior licensee/administrator Mylene Carreon will submit a detailed written explanation why she failed to notify the residents physician when the pressure injury was observed, why she failed to obtain medical care for the pressure injury, and why she re-admitted/retained R1 when the pressure injury was diagnosed as a stage 3.
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Based on information obtained during the investigation, the licensee/administrator did not comply with the cited section by retaining R1 at the facility who developed a stage 3 pressure injury due to improper wound care which posed an immediate health and safety and personal rights risk to R1
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4