197608280-6-26-2023-29-AS-JAPL-CTAP8G-20230630110532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608280
Report Date: 06/26/2023
Date Signed: 06/26/2023 02:35:24 PM

Unsubstantiated

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2023 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20230621083720

FACILITY NAME:	FOUR SEASONS ASSISTED LIVING CENTER LLC		FACILITY NUMBER:	197608280
ADMINISTRATOR:	CLARIZZE PUNIT		FACILITY TYPE:	740
ADDRESS:	12120 CHANDLER BLVD		TELEPHONE:	(818) 487-0770
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91607
CAPACITY:	49	CENSUS: 34	DATE:	06/26/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Ulka Sawghavi		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility elevator in disrepair.
Resident was injured while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted an initial 10-day complaint visit to the above facility. LPA Ascencio met with staff Ulka Sawghavi at 09:45 a.m. Entrance interview conducted.
On 06/21/2023, the Department received a complaint regarding the facility elevator is in disrepair and resident was injured while in care.

On 06/26/23, starting at 09:50 a.m., interview with Staff #1 (S1) revealed that the elevator stopped working on 06/24/2023. S1 proceeded to call the elevator company who came out that same day and fixed the elevator. While the elevator was inaccessible, facility staff assisted the residents who lived in the second (2nd) floor up and down the stairs.

Continued on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

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 3

Control Number 29-AS-20230621083720

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 06/26/2023

NARRATIVE

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Additionally, the residents on the 2^nd floor had the option of dinning in their rooms if they wanted too. Later that same day, interviews with various residents starting at 11:25 a.m. confirmed that the elevator was not working for a few hours but by the end of the day, the elevator was fixed. That same day, starting at 11:45 a.m., LPA Ascencio conducted a facility tour, which included the elevator. LPA Ascencio observed the elevator working properly at the time of visit. Based on evidence gathered throughout the investigation, the allegation of elevator in disrepair is deemed unsubstantiated at this time.

Lastly, regarding the allegation of resident was injured while in care. On 06/26/2023, interview with Resident #1 (R1) starting at 12:12 p.m. revealed that sometime in September of 2021, R1 was walking up the stair and fell. R1 stated the elevator was not working at the time and used the stairs to get to their room. R1 added that they felt pain in their abdomen and groin area. R1 stated they were not seen by a doctor and that Administrator Melissa Christopher observed the incident and assisted R1. That same day, a file review was performed for R1 at 12:40 p.m., revealing an incident report dated 02/21/2022. The narrative of R1’s incident reports indicates that R1 walked to the top of the stairs and R1 fell/slid at the top of the stairs. Former Administrator Christopher indicated in the incident report that they observed the fall, asked if R1 was ok and if R1 hit their head. R1’s response was that they were ok and did not need any medical attention. Administrator Christopher took R1 to their room in a wheelchair. Additionally, Administrator Christopher added that they checked on R1 a few days later and R1 stated they were feeling ‘OK’ and they did not need any medical attention.

Further file review revealed a discharge summary from the skilled nursing facility on 09/08/2021 indicating that R1 is not a fall risk and had genital complications, a Narrative Charting note, dated 10/11/2021, revealed that R1 requested and was transported to the hospital due to discomfort in genital area, and R1’s Primary Physician note indicating that on 10/21/2021, R1 was experiencing genital pain and abdominal pain due to the genital pain which also includes abnormalities in gait, and muscle weakness and mobility. Additionally, a hospital discharge summary was observed, dated on 02/17/2022, indicating that the reasons for visit was due to a headache and complications of the genital area. No other documentation regarding pain or discomfort was observed.

Continued on LIC 9099 - C Page 2

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230621083720

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 06/26/2023

NARRATIVE

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Although the date on the incident report differs from what R1 stated, documentation revealed that there was an incident regarding R1 having a fall while walking up the stairs. The incident report was written by Former Administrator Christopher, who indicated in the report, that they observed R1 falling, assisted R1 to their feet and offered medical attention via paramedics. In the incident reports, Administrator Christopher indicated on two (2) separate occasion that R1 refused medical attention and did not need medical attention. Moreover, a file review revealed that R1 sought medication attention on various occasion during any discomfort or pain and that facility staff assisted in obtain that medical attention by calling the paramedics or taking R1 to their primary doctors.

Thus, based on evidence gathered, there is not enough evidence to support the allegation of resident was injured while in care. Therefore, the allegation is unsubstantiated at this time.

Exit interview conducted and a copy of the report was issued to Staff Ulka Sawghavi.

Page 3

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC9099 (FAS) - (06/04)

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