197608511-11-16-2023-31-AS-AJKK-D2MND7-20240220092150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608511
Report Date: 11/16/2023
Date Signed: 11/16/2023 02:13:17 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/15/2020 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20200515121104

FACILITY NAME:	CASA BLANCA HOMECARE		FACILITY NUMBER:	197608511
ADMINISTRATOR:	MARILOU A. ANDREAS		FACILITY TYPE:	740
ADDRESS:	17216 GOYA STREET		TELEPHONE:	(818) 366-2234
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	4	CENSUS: 2	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Marilou Andreas		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Due to neglect, resident has multiple unstageable pressure injuries

INVESTIGATION FINDINGS:

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This is an amended report to the complaint investigation report issued by Licensing Program Analyst (LPA) Martha Guzman Chavez on February 3, 2022. The initial findings to the above allegation was substantiated at that time. The Licensee had since submitted a first and second level appeal, which was reviewed by the Department. Based on this review, the Licensee provided a chronological timeline of events of Resident 1’s (R1) condition, which was being treated by home health, and by facility staff with instruction from home health, for maintenance, moisturizing, prevention, and ongoing care of R1. Furthermore, information submitted by the Licensee reveal that on May 11, 2020, R1 was transferred to the hospital per physician’s instructions, due to R1 experiencing pain and discoloration. At admission to the hospital, on May 11, 2020, medical records indicate that R1 was noted to have a mild skin breakdown, and a diagnosis of a “mild stage II decubitus ulcer”. On May 12, 2020, while still at the hospital, a wound care clinician examined R1’s wound to progress and become an Unstageable pressure injury.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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 31-AS-20200515121104

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA BLANCA HOMECARE	FACILITY NUMBER: 197608511
	VISIT DATE: 11/16/2023

NARRATIVE

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Based on the Department's review of this appeal and supporting documents, it was determined that there is a lack of sufficient evidence to support the citation issued by LPA Guzman Chavez issued under section 87615(a)(1) Prohibited Health Condition. Therefore, the appeal is granted, and the citation with the related $500 civil penalty is dismissed. The allegation finding is changed from Substantiated to Unsubstantiated. The Licensee is advised and a copy of this report given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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