197608280-8-8-2023-29-AS-DPEA-D7Q5VC-20240731201718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608280
Report Date: 08/08/2023
Date Signed: 08/08/2023 06:23:09 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
06/08/2023 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20230608083803

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:	08/08/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Ulka Sawghavi		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff did not seek medical attention for resident in care
Staff threatened a resident in care
Staff spoke inappropriately to a resident in care
Staff do not serve nutritious meals

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility. LPA Ascencio met with Staff Ulka Sawghavi at 12:45 p.m. Entrance interview conducted.

On 06/08/2023, the Department received a complaint alleging that staff did not seek medical attention for resident in care, staff threatened a resident in care, staff spoke inappropriately to a resident in care, and staff do not serve nutritious meals. On 06/26/2023, interview with Resident #1 (R1) starting at 12:12 p.m. revealed that sometime in 2021, R1 was living in the second (2nd) floor, walked up the stairs and had a fall. R1 indicated that the elevator was not working to go up to the second floor. R1 added that when they fell, R1 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 back to their room.

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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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 6

Control Number 29-AS-20230608083803

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: 08/08/2023

NARRATIVE

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Later that day, during R1’s file review, an incident report, dated 02/21/2022, indicated 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 on the report, that Administrator Christopher checked on R1 a few days later and R1 stated feeling ‘OK’ and that 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.

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 but R1 refused services. Incident reports also indicated that Administrator Christopher, on two (2) separate occasion, spoke to R1 who refused medical attention and stated they did not need medical attention. Moreover, a file review revealed that R1 sought medication attention on various occasion when having discomfort or pain. Additionally, facility staff assisted in obtain that medical attention by calling the paramedics or taking R1 to their primary doctor.

Thus, based on evidence gathered, there is not enough evidence to support the allegation that staff did not seek medical attention for resident in care. Therefore, the allegation is unsubstantiated at this time.

A similar allegation with the same resident was unsubstantiated on 06/26/2023.

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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20230608083803

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: 08/08/2023

NARRATIVE

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Regarding the allegations of: staff threatened a resident in care and staff spoke inappropriately to a resident in care.

On 06/13/2023, LPA Ascencio conducted an interview with R1, starting at 1:00 p.m. Interview with R1 revealed similar details to an unsubstantiated complaint dated 05/16/2023. LPA Ascencio asked if R1 had additional information regarding the allegations. R1 stated that LPA Ascencio had all the details from the previous conversation relating to the matter, nothing has changed.

Although a new complaint was filed for allegations that were previously unsubstantiated on 05/16/2023, interview with R1 revealed that there is no additional evidence that support the claims that staff threatened a resident in care and staff spoke inappropriately to a resident in care. The following is a summary of the unsubstantiated findings delivered on 05/16/2023.

On 05/16/2023, LPA Ascencio conducted an interview with Administrator Punit at 10:15 a.m. Interview with Administrator Punit revealed that Resident #1 (R1) has been living at the facility for over a year and is on the Assisted Living Waiver Program (ALW). Monthly, the ALW program pays a majority of R1's boarding and care fees, while R1 is responsible for what ALW does not cover. Administrator Punit stated R1 has not been paying their portion since moving in last year, raking up a fee of over $15,000. Administrator Punit also mentioned that they have spoke to R1 various time regarding the billing statement and possible eviction for non-payment, but was not mentioned in a threatening way.

We did have Staff #1 (S1) last week on 05/12/2023, to speak to R1. Although, I am not sure what was said, we could not hear any yelling or cursing coming from the room. I know that S1 was going to talk to R1 regarding their outstanding balance, and that the eviction topic would not come up. Lastly, R1 has been refusing to pay their portion stating the facility should be charging Medicare and Medi-Cal for their stay at the facility.

Later that same day, interview with R1 at 10:40 a.m., revealed that the facility has spoken to R1 various occasion regarding the billing. R1 added a staff person arrived at their room on 05/12/2023 talking about how they want to help me but then started to talk about getting "their money." Afterwards, that staff person began to yell at me and cursed at me, calling me a derogatory, racial slur. Lastly, R1 added that the staff person spoke to them about eviction because I haven’t paid, but R1 reiterated they will not be moving from the facility.
Continued on LIC 9099 - C Page 3

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20230608083803

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: 08/08/2023

NARRATIVE

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That same day, interview with S1, starting at 11:20 a.m. revealed that they spoke to R1 on 05/12/2023 regarding ways the facility can assist R1 in obtained additional resources such as Social Security Income (SSI) funds. S1 stated the conversation was going great, until the topic of money and the outstanding balance came up. S1 added that R1 began to yell and curse at S1. S1 added they left the room not wanting to cause any emotional disturbance to R1. Lastly, S1 stated they were professional and understanding toward R1, and did not threaten R1 with any eviction. Later that day, interview with residents starting at 01:33 p.m. revealed that staff are nice, professional and have not cussed at any resident at the facility.

Although the R1 has an outstanding balance of $15,000 for not paying their portion of rent, interview with Administrator Punit revealed that the facility is looking at additional resources to help R1 obtain additional funds to create a payment plan for their balance. Administrator Punit stated they will not be evicting R1 at this moment as the facility wants to provide every resource available to R1 before doing so. Even though R1 stated they were called a racial slur by S1, and S1 stated they were professional and polite when speaking with R1, it is unsure what was said during the conversation between R1 and S1. Thus, there is insufficient evidence to prove that the allegation of Staff threatened resident of eviction and Staff spoke inappropriately to resident occurred. Thus, the allegations are deemed unsubstantiated at this time.

LPA Ascencio and Administrator Punit reviewed policies and procedures regarding the eviction process.

Similar allegations regarding the same resident were unsubstantiated on 05/16/2023.

Lastly, regarding the allegation of staff do not serve nutritious meals. Interview with six (6) residents on 06/26/2023 revealed that the food is good. The food comes from the skilled nursing facility (SNF) and is delivered to the residential dining room. The staff assist with plating the food and can serve the food at a hot temperature. In addition, resident interviews indicated that they would prefer a different variety of meals instead of a rotating schedule. Lastly, although resident interviews indicated that they enjoy the food, other residents indicated that the food is cold, is of low quality and is not known what food item they are eating. That same day, starting at 11:00 a.m., LPA Ascencio conducted a tour of the facility kitchen. The tour revealed a clean and well-maintained kitchen area with proper utensils and kitchenware. Additionally, LPA Ascencio observed a variety of perishable and non-perishable goods for resident consumption.

Continued on LIC 9099 - C Page 4

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20230608083803

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: 08/08/2023

NARRATIVE

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During the kitchen tour, an interview with Head Chef revealed that they create a monthly dining calendar for the Assisted Living Facility and SNF. The menus involve a balanced meal consisting of protein, carbohydrates, and vegetables. The Head Chef added that if a resident does not like the food item on the calendar, they have a side menu they can choose consisting of sandwiches or salads. That same day, LPA Ascencio received menus for the month of June 2023 revealing all menus had a balance of protein, carbohydrates and vegetables for lunch and dinner. That same day, when conducting resident interviews, LPA Ascencio observed the lunch meals for 6 residents, which consisted of chicken in a red sauce, mashed potatoes, and cooked squash.

Although some resident interviews revealed that they were displeased with the food not being of good quality, observation and additional interviews revealed that the food is of good quality and enjoy what is being served daily. Thus, based on evidence gathered, the allegation of facility food is not of good quality is deemed unsubstantiated at this time.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6