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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607438
Report Date: 09/08/2021
Date Signed: 09/08/2021 01:41:09 PM

Document Has Been Signed on 09/08/2021 01:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BOROL PLACEFACILITY NUMBER:
197607438
ADMINISTRATOR:KATHY SHADEKO-ADEDIGBAFACILITY TYPE:
735
ADDRESS:2616 DAUNET AVENUETELEPHONE:
(805) 584-2995
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 3DATE:
09/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Isaac AdelekeTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Teresa Camara, Ashley Smith and Salia Walker initiated a Case Management – Incident visit today. Administrator Kathy Adedigba (Adedigba) was not available so LPAs met with back-up administrator Isaac Adeleke (Adeleke).

On 07/09/21, this facility submitted a Special Incident Report (SIR) noting staff found a pressure injury on the upper buttocks of client #1 (C1) while assisting C1 with showering. C1 was taken to an urgent care and then to the hospital where C1 was admitted. C1 was discharged from the hospital on 07/12/21 and set up with home health services for wound treatment.

On 08/14/21, this facility submitted an SIR noting on 08/12/21 they spoke with the home health agency as C1’s wound was smelling badly, but home health said that was not unusual. Staff took C1 back to the urgent care on 08/13/21, and they were instructed to take C1 to the hospital. C1 was admitted to the hospital for wound treatment and discharged on 08/20/21 with further home health wound care.

On 09/01/21, this facility submitted an SIR on 08/30/21, noting that C1 went to urgent care for a visit and learned C1’s wound progressed to a Stage 3. On 08/31/21, they took C1 back to the hospital. Abedigba notified the hospital physician that C1 cannot return to the facility as a Stage 3 pressure injury is a prohibited health condition. C1 was admitted to the hospital for wound care and discharged to a skilled nursing facility.

On 09/02/21, Adedigba submitted a copy of home health paperwork dated 08/04/21 which noted C1 had a Stage 3 wound on 07/27/21. During today's visit, a file review conducted at 12:30 p.m. revealed a note from a physician dated 08/13/21, which indicated C1 had a Stage 3 pressure injury that was not improving. This facility did not submit an exception for C1 to be retained with the stage 3 pressure injury.

Based on the investigation, there is sufficient evidence to support that C1 remained in the facility for several weeks with a prohibited health condition. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and a copy of the report issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2021 01:41 PM - It Cannot Be Edited


Created By: Teresa Camara On 09/08/2021 at 01:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BOROL PLACE
FACILITY NUMBER: 197607438

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2021
Section Cited
CCR
80091(a)(4)

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80091(a)(4) Prohibited Health Conditions. In adult CCFs clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained. (4) Stage 3 and 4 dermal ulcers.
This requirement is not met as evidenced by:
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The administrator agreed to the following: Currently C1 has been relocated out of the facility and will not be accepted back at this time. Plan of Correction met.
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Based on the investigation the licensee did not comply with the section cited above as C1 was retained with a Stage 3 pressure injury which poses an immediate health and safety risk to clients 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021


LIC809 (FAS) - (06/04)
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