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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608309
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:57:13 PM

Substantiated


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
09/15/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20210915162921
FACILITY NAME:ETTA ISRAEL CENTER #4FACILITY NUMBER:
197608309
ADMINISTRATOR:HEIDI SCHOFIELDFACILITY TYPE:
735
ADDRESS:6101 BLUEBELLTELEPHONE:
(818) 890-1709
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 5DATE:
04/14/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Heidi Schofield, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility did not obtain consent from responsible party prior to client undergoing dental procedures.

Facility did not report concerns regarding client's health to responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit to deliver the investigation finding for the above allegations. The LPA met with administrator Heidi Schofield at 11:37 a.m., and explained the reason for the visit.

On 09/22/2021, LPA Walker conducted an initial complaint visit. Between 2:10 p.m. and 4:30 p.m., the LPA conducted a physical plant tour, interviewed clients, and staff; as well as reviewed and obtained copies of documents pertinent to the investigation. The LPA determined, at that time, that further investigation was required.

On 11/12/2021, LPA Walker conducted a telephone interview with Administrator Heidi Schofield.

Continue on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
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 29-AS-20210915162921
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: ETTA ISRAEL CENTER #4
FACILITY NUMBER: 197608309
VISIT DATE: 04/14/2022
NARRATIVE
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During today’s visit, the LPA conducted a physical plant tour at 11:39 a.m., to ensure there are no health and safety hazards.
Regarding the allegation, ‘Facility did not obtain consent from responsible party prior to client undergoing dental procedures,’ the complainant’s concern is that the facility failed to provide services as specified in client #1’s (C1’s) Individual Program Plan (IPP) Progress Report which was approved on 04/29/2021, which required the facility to obtain consent from C1’s responsible party anytime C1 required any type of medical or dental procedure.

During the investigation, the LPA conducted a record review, interviews with the complainant, facility staff, and the administrator. The interview with the complainant revealed that the administrator was aware and was in agreement that before moving forward with any dental treatment, it would be discussed with C1’s family. Interviews with facility staff revealed that the administrator ‘notifies the client’s family’ regarding all medical and dental concerns. An interview with the administrator revealed that the administrator failed to obtain consent from C1’s Responsible Party (RP) prior to C1 undergoing dental procedures. The administrator also revealed that in May of 2021, C1 was taken to their follow up dental appointment where a dental procedure was done without consent of C1’s responsible party; due to the fact that the facility was un aware of additional procedure being conducted during that dental visit. A record review revealed that C1’s responsible party is ‘authorized to make any medical appointments and decisions and provider needs to discuss and get approval before any procedure is done.’

Based on record review, interviews with the complainant, staff, and the administrator, there is sufficient evidence to support the allegation ‘Facility did not obtain consent from responsible party prior to client undergoing dental procedures.’ Therefore, this allegation is deemed Substantiated at this time.

Regarding the allegation, ‘Facility did not report concerns regarding client's health to responsible party,’ the complainant’s concern is that the facility failed to notify C1’s responsible party concern’s regarding C1’s health as specified in their IPP. C1 had a loose tooth, and the dentist informed staff that a bridge would be required when the tooth feel out. However, the responsible party was not informed that two (2) teeth would be removed, and subsequent teeth would be replaced.
Continue on LIC9099C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20210915162921
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: ETTA ISRAEL CENTER #4
FACILITY NUMBER: 197608309
VISIT DATE: 04/14/2022
NARRATIVE
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During the investigation, the LPA conducted interviews with the administrator, and the complainant. The interview with the complainant revealed that the facility did not notify the responsible party of concerns with C1’s health and discovered on a visit to the facility that a dental procedure was done on C1 without the responsible party’s knowledge. An interview with the administrator revealed that the facility ‘didn’t know’ C1’s dentist was planning on performing an additional procedure and ‘take out two more teeth.’ Therefore, the facility was unable to report update the responsible party regarding the client’s health, as they had no knowledge that the dentist planned on removing two (2) more teeth. The administrator also stated that the facility ‘will take responsibility,’ though they allegedly had no knowledge of the additional procedure.

Based on interviews with the complainant, and the administrator, there is sufficient evidence to support the allegation ‘Facility did not report concerns regarding client's health to responsible party.’ Therefore, this allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.), and cited from the California Code of Regulations, Title 22; Division 6; Chapter 6. Exit interview conducted, a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20210915162921
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: ETTA ISRAEL CENTER #4
FACILITY NUMBER: 197608309
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2022
Section Cited
CCR
85072(b)(2)
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85072(b)(2) Personal Rights: (b)The licensee shall insure that each client is accorded the following personal rights. (2)To have the facility inform his/her relatives and authorized representative.. of activities related to his/her care and supervision, including..
This requirement was not met as evidenced by:
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The Licensee has agreed to do the following:
1. Submit a statement to CCLD indicating the steps the facility will take in the future to avoid repeating citation 85072(b)(2).
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Based on record review and interviews, the licensee did not comply with the section cited above as the facility did not report concerns and obtain consent from C1's responsible party before undergoing dental procedure, which poses a potential health and safety risk to persons 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4