197608280-10-2-2024-29-AS-KLOZ-DAH2J5-20241028172547

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608280
Report Date: 10/02/2024
Date Signed: 10/02/2024 02:32:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
09/30/2024 and conducted by Evaluator Erica Mosley

COMPLAINT CONTROL NUMBER: 29-AS-20240930164354

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: 32	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Activities Coordinator/ Social Worker, Ulka Sanghavi		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident moved to higher level of care without consent

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erica Mosley conducted an initial 10-day complaint visit to investigate the above allegation. Upon arrival at approximately 9:40 am, LPA Mosley was greeted by Activities Coordinator/ Social Worker, Ulka Sanghavi who called the Administrator to inform them of the visit. The Administrator Clarizze Punit was not able to attend and designated Ulka Sanghavi to sign the report and the reason for the visit was explained.

On 09/30/2024, the Department received a complaint regarding the following allegation, Resident moved to higher level of care without consent. LPA toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations.

Report Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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 29-AS-20240930164354

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 10/02/2024

NARRATIVE

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Report Continued from LIC9099...

On the allegation, Resident was moved to higher level of care without consent it is the concern of the reporting party (RP) that Staff #1 (S1) sent Resident #1 (R1) to a higher level of care, skilled nursing facility (SNF) due to R1 having multiple falls which was untrue and R1 should not be at the SNF. The SNF R1 is currently residing at is located in the same building as the facility and a collateral visit was also conducted at this location during the investigation. To investigate this complaint, LPA requested pertinent documents to the investigation. The LPA also conducted interviews with the Administrator, two (2) Assisted Living staff, SNF Director of Nursing (DOR), one (1) SNF LVN Unit Manager, and resident R1 between 10:10am to 12:57pm.

Interviews with assisted living staff revealed that R1 returned to the facility from the hospital on 09/06/2024 and on 09/10/2024 R1 had an unwitnessed fall in the bedroom. R1’s roommate, Resident #2 (R2) found R1 on the floor of the bedroom and immediately contacted second floor staff. Staff #2 (S2) responded and found R1 on the floor of the bedroom. S2 assisted R1 up, however S2 noticed a delay in speech and confusion. S2 called 911, R1 consented and was transported to the hospital. Interviews with SNF staff revealed that R1 had doctor orders to be released to SNF when they were discharged from the hospital. Record review and documents obtained revealed that R1 had a fall, loss consciousness, compression fracture, and UTI requiring antibiotics. R1 signed discharge summary indicating that R1 will be released to SNF to continue antibiotics along with occupational therapy and physical therapy. Interviews with staff and record review support that R1 was moved to a higher level of care with consent and physician orders for the health of the resident. The LPA attempted to interview R2 but they were unavailable for interview.
Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Resident was moved to higher level of care without consent is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

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