197608549-2-9-2024-31-AS-NMAN-D332VD-20240304164347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608549
Report Date: 02/08/2024
Date Signed: 02/09/2024 09:20:14 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
01/31/2024 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20240131114515

FACILITY NAME:	GLENDALE CAREHOME		FACILITY NUMBER:	197608549
ADMINISTRATOR:	EVANGELINE URSUA		FACILITY TYPE:	740
ADDRESS:	714 MILFORD STREET		TELEPHONE:	(818) 640-2912
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91203
CAPACITY:	6	CENSUS: 0	DATE:	02/08/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:			TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained unexplained injuries while in care.
Staff did not give notice of changes in a resident’s condition.
Staff did not ensure that a resident was dressed appropriately for the weather.
Staff did not maintain accurate records on a resident.
Staff did not ensure that a resident was adequately fed.
Staff did not ensure that a resident’s nails were cut.
Staff did not seek a resident timely medical attention.
Staff left a resident in soiled diapers/bed linens for extended periods of time.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint visit to the facility for the above noted allegations. Please note that the facility closed as of 01/25/2024, due to the licenses's retirement. LPA Valenzuela attempted to contact the Administrator and explain the purpose of this visit. Prior to this visit on 02/02/24 at 11:30am, LPM Margaryan interviewed the Administrator over the phone and obtained requested documentation. At the time of this investigation on 2/05/2024 at 1:30pm, LPA Valenzuela reviewed Resident #1 (R1's) requested facility files, including but not limited to R1's physician report, other medical records, copies of incident reports and additional pertinent documents. In addition, LPA made an attempt to contact R1's responsible party, but to no avail.

Resident sustained unexplained injuries while in care. It was reported on 01/31/2024, that resident sustained a severely enlarged and bruised right knee and that the facility failed to seek medical attention.

Continue on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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 31-AS-20240131114515

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLENDALE CAREHOME	FACILITY NUMBER: 197608549
	VISIT DATE: 02/08/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Administrator stated that R1 was residing at the facility since 2019. R1 moved out on 01/19/2024 due to closure of the facility. R1's medical appointments were arranged by their responsible party. The Administrator stated that R1 was never injured at the facility. R1's right knee was swollen and bruised for a long time. Although R1 was getting home care services and physical therapy, the condition of R1's knee was not getting better. Physical therapist suggested to do an X-ray of R1's knees. They did the X-ray and informed R1' family that the right knee transplant was dislocated, causing pain, swollenness and discoloration. A review of available records supported the information received from the Administrator.
During this investigation, LPA was not able to contact R1's responsible party to obtain additional information.

Based on the interviews and record review, there is insufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Staff did not give notice of changes in a resident's condition. It was alleged that while in the facility R1's knee implant was dislocated, and R1 had fractured tibia, and the family was not notified.

The Administrator stated that R1's overall condition was not changed. R1's responsible party was informed from the doctor about the dislocation of R1's right knee and fracture after they performed X-rays. R1's physical therapist told the Administrator about the dislocated implant and the doctor scheduled an appointment to remove R1's implant(s).

A review of R1's file and other available records supported the information received from the Administrator. A review of other available records did not reveal any information to verify changes in R1's condition and responsible party was not able to provide more information to support the allegation.

Therefore, based on interviews and record review the allegation is UNSUBSTANTIATED at this time.

Staff did not ensure that a resident was dressed appropriately for the weather. It was alleged that on 01/19/2024, while R1 was getting ready to be relocated to the new facility, R1 was dressed in a hospital gown and was left outside in the cold in under 50 degree temperature.

Continue on 9099-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20240131114515

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLENDALE CAREHOME	FACILITY NUMBER: 197608549
	VISIT DATE: 02/08/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Administrator denied leaving R1 outside of the facility. She stated that R1 was very aggressive and combative towards staff, and it was very hard to dress her. However, R1 was never left in a hospital gown. R1 was always appropriately dressed, and staff was providing a blanket to her as well as to the other residents if needed. A review of R1's physician report supported the information from the Administrator. No other information was available during this investigation to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Staff did not maintain accurate records on a resident. It was reported that R1's physician's report dated 09/0/23, contained inaccurate information regarding the weight of R1. R1's weight was recorded as being 132lbs, Also a wrong diagnosis of anorexia was listed. The Administrator stated that he physician report was completed by the doctor and the information was provided based on their assessment and observation. Physician report does not indicate that R1 had anorexia. Indeed, a review of R1's physician report does not indicate that R1 has a diagnosis of anorexia and it lists R1's weight has being 132lbs. The information available during the investigation does not verify the allegation. Hence, the allegation is UNSUBSTANTIATED at this time.

Staff did not ensure that a resident was adequately fed. It was reported that staff did not ensure the R1 was eating a whole meal. The administrator stated that R1 never had issues with the food. She was able to feed herself and at times she did not want to eat the whole meal and they were not forcing her. R1 was a petite person and never suffered from weight loss. A few months ago, staff noticed that R1 did not have an appetite and was confused. Apparently the resident had UTI which was affecting R1's appetite. During this investigation, LPA was unable to contact R1's responsible party to obtain more information. Per physician report R1 was 132lbs and no other records were available to identify R1's weight.

Based on information obtained from the interviews and record review there is no pertinent information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Staff did not ensure that a resident's nails were cut. It was reported that R1 had long unattended toenails and no proactive podiatry care was arranged. The Administrator stated the R1's medical care was arranged by their family members. The Administrator spoke with the resident's responsible party a few times to bring podiatrist to cut R1's nails. However, it was not arranged. Home Health Care nurses also were aware of R1's need for podiatry care and the Administrator was not sure why it was not provided. Continue on 9099-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20240131114515

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLENDALE CAREHOME	FACILITY NUMBER: 197608549
	VISIT DATE: 02/08/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Valenzuela was unable to speak to R1's responsible party to obtain additional information. The documents reviewed during this investigation did not contain any information to support the allegation.

Therefore, based on the information obtained during this investigation, the allegation is UNSUBSTANTIATED at this time.

Staff did not seek a resident timely medical attention. It was alleged that resident had UTI and staff did not seek medical attention. Administrator stated that there was no delay in R1's medical attention. All medical appointments for R1 were arranged by R1's family/responsible party. Home Health nurses were assisting R1 for pain management. A few months ago, R1's behavior changed and they were more confused. The family was informed that they were sending R1 to the hospital. At first the family disagreed. However, based on the change of R1's appearance and increasing confusion, 911 was called. R1 was sent to the hospital and that is where they were diagnosed with UTI. Resident received required treatment and returned to the facility. The information revealed from the available records verified the information provided by the Administrator. No other information was available to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Staff left a resident in soiled diapers/bed linens for extended periods of time. It was reported that R1 was left in soiled diapers and linens for a long time. The Administrator denied leaving resident in soiled diapers. She stated that the resident was very aggressive and combative towards staff. To change R1, staff had to find a good time, otherwise R1 would not allow staff to touch them Staff was able to change R1 at least 3 times a day. R1 was allowing staff to change them when she was feeling uncomfortable because of a wet diaper. R1's family know about it and at times they were helping staff to convince R1 to change their diapers. A review of available documents did not reveal any information to support the allegation. Hence, the allegation is UNSUBSTANTIATED at this time.

Due to facility closure, LPA was unable to obtain electronic signature, therefore a copy will be email to the former Administrator to the email address on file.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4