197608363-6-19-2023-29-AS-DPEA-CT8NNY-20230628103727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608363
Report Date: 06/19/2023
Date Signed: 06/19/2023 03:22:59 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
03/09/2023 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20230309161250

FACILITY NAME:	LAKE BALBOA BOARDING CARE		FACILITY NUMBER:	197608363
ADMINISTRATOR:	ANAIT ASATRIAN		FACILITY TYPE:	740
ADDRESS:	15830 MARLIN PLACE		TELEPHONE:	(818) 793-9814
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 2	DATE:	06/19/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Anait Asatrian		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident developed an unstageable pressure injury while in care.
Resident sustained injuries while in care.
Resident's grooming needs are not being met.

INVESTIGATION FINDINGS:

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**This is the new amended report that includes additional information, which supersedes the report issued on 06/09/2023 **

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Balisi met Administrator Anait Asatrian and explained the reason for the visit.

On 03/09/2023, the Department received a complaint regarding allegations of Neglect/Lack of Supervision and Care. It was alleged that Resident #1 (R1) developed an unstageable pressure injury and sustained injuries while in facility care. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Lorraine Patterson.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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-20230309161250

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: LAKE BALBOA BOARDING CARE	FACILITY NUMBER: 197608363
	VISIT DATE: 06/19/2023

NARRATIVE

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Continued from 9099
On 03/10/2023, from 10:09 a.m. to 12:00 p.m., LPA Brian Balisi initiated an unannounced complaint
investigation for the allegations listed above.Upon arrival LPA Balisi met with Anait Asatrian, Administrator, and explained the reason for the visit.

At approximately 10:00 a.m., the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation.

Investigator Patterson conducted interviews on 04/17/2023, from approximately 2:01 p.m. to 2:10 p.m., with R1’s resident representative and the complainant/reporting party; on 04/18/2023, from approximately 12:50 p.m. to 2:00 p.m., with facility staff, Administrator, R1’s resident representative, and an attempted interview with R1. In addition, the investigator reviewed Sherman Oaks Hospital medical records and facility file documents related to R1.

Regarding the allegations “Resident #1 (R1) developed an unstageable pressure injury while in care” and “Resident #1 (R1) sustained injuries while in care”, the complainant reported they were made aware, per the wound nurse report, that R1 who was admitted to Sherman Oaks Hospital due to respiratory failure presented on admission with a sacral unstageable pressure injury; a right heel deep tissue injury (DTI); a left heel scab with redness; and discoloration/dry abrasion on upper back. The investigator found the following during the course of their investigation.

During the review of the hospital’s medical records for R1, the investigator noted there were no wound photographs in the medical file and did not see an initial physical exam which noted R1 had a Stage III or unstageable pressure injury or any wound injuries on arrival. The medical information review of symptoms timeline was unclear as far as when R1’s sacral pressure injury and body wounds were first seen.
The Special Incident Report (SIR) submitted by the facility, dated 03/09/2023, revealed that on 03/02/2023, R1’s resident representative was notified that R1 was coughing a lot and had a Stage I pressure injury on sacral. The Administrator also requested the American Home Health Care come to the facility to observe the wound. By the next day, 03/03/2023, R1 had a pressure ulcer injury, Stage II on coccyx and a right heel blister. R1 was sent to the Sherman Oaks Hospital Emergency Room for the cough and hospitalized with pneumonia.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230309161250

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: LAKE BALBOA BOARDING CARE	FACILITY NUMBER: 197608363
	VISIT DATE: 06/19/2023

NARRATIVE

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Continued from 9099-C
The SIR further stated R1 was taking Levofloxacine 500 mg 1 tablet daily for 4 days and “open pressure ulcer and wound/blister on right heel. Treatment provided by Pegusus Home Health Care daily”.

Facility staff and R1’s resident representative denied the allegations. R1’s resident representative reported the day prior to R1’s hospitalization R1 had a Stage I pressure injury on sacral, and that the facility made the proper notifications and continued to check and care for R1. R1’s resident representative further reported that R1 waited in the Emergency Department (ED) for hours, approximately four (4) to five (5) hours, before a doctor saw R1 for respiratory failure, and that they complained about the care which hospital staff provided to R1 while R1 was hospitalized. R1’s resident representative stated during R1’s first hospital assessment they spoke to a nurse who reported R1 only had a sacral Stage II pressure injury and there were no other injuries reported to them.

Based on statements and documentation provided, the Department does not have sufficient evidence to determine that there was negligence or lack of supervision on behalf of the facility staff. While the allegations may be valid, there is insufficient evidence to corroborate that R1 developed an unstageable pressure injury and sustained injuries while in care of the facility. Therefore, the allegations that “Resident #1 (R1) developed an unstageable pressure injury while in care” and “Resident #1 (R1) sustained injuries while in care” are deemed unsubstantiated at this time.

Regarding the allegation that "Resident's grooming needs are not being met", it was alleged that R1's toenails were long and curled. Interviews conducted with family and staff revealed that only a podiatrist is able to clip R1's toe nails and it was communicated that a podiatrist came to the facility on a regular basis. Interviews with the family member of R1, who visited R1 on a regular basis, expressed they never had any concerns for R1's nails not being groomed or well-kept. On 06/19/2023, LPA observed the nails of two (2) residents in care to be groomed and well-kept. Hospital records reviewed from admittance on 03/03/2023 to discharge on 03/08/2023 did not indicate any observation of long nails at this time. Based on information gathered throughout the course of the investigation, the Department does not have sufficient evidence to determine that R1's nails were not being cut. Therefore, the above allegation that R1's grooming needs are not being met is deemed Unsubstantiated at this time.

Exit interview conducted, a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC9099 (FAS) - (06/04)

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