197608466-9-29-2020-29-AS-JAPL-BTZ33E-20201001175324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608466
Report Date: 09/29/2020
Date Signed: 09/29/2020 04:46:10 PM

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
05/04/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20200504091534

FACILITY NAME:	BELMONT VILLAGE ENCINO		FACILITY NUMBER:	197608466
ADMINISTRATOR:	DRACHENBERG, CYNTIA		FACILITY TYPE:	740
ADDRESS:	15451 VENTURA BLVD		TELEPHONE:	(818) 788-8870
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY:	150	CENSUS: 106	DATE:	09/29/2020
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Cyntia Drachenberg		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Failure to provide adequate care & supervision resulting in Stage 3 Pressure Injury
Failure to comply with reporting requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith initiated a subsequent complaint investigation to issue findings for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Executive Director Cyntia Drachenberg.

On 05/04/2020, the Department received a complaint in which it was alleged Resident #1 (R1) developed a Stage 3 Pressure Injury due to staff negligence. On 05/05/2020, LPA E. Miller conducted the Initial 10-Day complaint visit at 3pm via FaceTime to interview the Administrator and request documents. Community Care Licensing Division’s Investigations Branch (IB) Investigator Robert Kujawa was assigned to the investigation. Investigator Kujawa interviewed a responsible party on 07/07/2020 at 3:25pm; interviewed facility staff on 7/10/2020 at 12:31pm, on 7/15/2020 at 4:05pm, 7/22/2020 at 11:33am, on 7/23/2020 at 12:32pm; interviewed a hospice representative on 7/24/2020 at 10:50am; and, reviewed hospice and medical records on 07/14/2020.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2020

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-20200504091534

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: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 09/29/2020

NARRATIVE

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Regarding the allegation: Failure to provide adequate care & supervision resulting in Stage 3 Pressure Injury
The complainant alleged that due to neglect, resident #1 (R1) developed a Stage 3 pressure injury. Interviews conducted and records reviewed revealed that R1 was admitted to the facility on 3/13/2020. The appearance of redness on R1’s sacral area was initially noted on Facility Nursing Notes on 3/19/2020, and was subsequently noted on 3/25/2020, 3/26/2020, 3/31/2020, 4/10/2020, 4/11/2020, 4/12/2020, 4/13/2020 and 4/28/2020. On those days listed, facility LVNs observed and treated R1's sacral area and R1 was repositioned every two hours for the prevention of pressure injuries. In addition, medical records demonstrated that ointment cream, which was prescribed to R1 prior to being admitted to this facility, was applied three times a day to the sacral area.

Interviews revealed that on 4/30/2020, the redness on R1’s sacral area was observed to have worsened. Interviews and supporting documentation confirmed that the facility LVN submitted an order for Home Health to further evaluate the wound. Concurrently, a referral for hospice care was sent on 4/30/2020. R1 was admitted to hospice on 5/1/2020 and the initial examination identified the wound as a Stage 3 pressure injury.

Interviews and records review supported the claim that R1 was receiving proper wound treatment prior to the wound being observed by a hospice nurse. Facility LVNs, whom are identified as appropriately skilled professionals, were regularly observing R1's sacral area. The frequency of R1 being repositioned and the application of ointment cream was also documented, and there was no evidence of negligence. Interviews conducted with medical professionals responsible for R1’s care believe that the development of pressure injuries could be caused by the decline of a resident’s health, not due to abuse or neglect.

Based on the investigation and the information obtained, there is insufficient evidence to support the claim that the facility failed to provide adequate care and supervision resulting in a Stage 3 Pressure Injury. The facility staff documented the progression and care of the wound and once it appeared to have worsened, protocol was followed by alerting management and submitting a request for appropriate care and evaluation. This allegation is deemed Unsubstantiated at this time.

CONT 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2020

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200504091534

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: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 09/29/2020

NARRATIVE

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Regarding the allegation: Failure to comply with reporting requirements
Regarding the allegation, the complainant alleged that R1’s change of condition was not reported to the appropriate parties as required. A review of facility nursing notes demonstrates that the resident’s responsible party and primary care physician were notified on several occasions as it relates to R1’s condition. For example, documentation showed that the appropriate parties were notified regarding R1’s complaints of wrist pain on 4/1/2020, COVID-19 results were communicated on 4/8/2020, symptoms of cough and loose stools were communicated on 4/27/2020, and R1’s continued symptoms of dehydration and low appetite were communicated on 4/29/2020 and 4/30/2020. On 4/30/2020, due to R1’s worsening condition, the facility sent a referral for hospice care that afternoon and R1’s physician and responsible party were in agreement. This facility provided written notification of the initiation of hospice services to Community Care Licensing within five business days of R1 being admitted to hospice. As previously noted, the treatment of the redness observed on R1’s sacral area was documented and at the point that the area appeared to have worsened, the referral for home health was sent.

Based on the investigation and the information obtained, there is insufficient evidence to support the claim that the facility failed to comply with reporting requirements. This allegation is deemed Unsubstantiated at this time.

No citations issued at this time. Exit interview conducted. A copy of the report was provided via emailed for signature.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2020

LIC9099 (FAS) - (06/04)

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