197608595-4-4-2022-31-AS-NMAN-CFFT8F-20220616143016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608595
Report Date: 04/04/2022
Date Signed: 04/04/2022 12:53:14 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2022 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20220201084111

FACILITY NAME:	NEST, THE		FACILITY NUMBER:	197608595
ADMINISTRATOR:	MICHELLE WEISMAN		FACILITY TYPE:	740
ADDRESS:	4100 HAYVENHURST AVENUE		TELEPHONE:	(818) 990-6896
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	6	CENSUS: 6	DATE:	04/04/2022
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Herschel Weisman		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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9

Facility authorized hospice services for resident without resident's responsible party consent.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA met with Co-Administrator, Herschel Weisman, and explained the reason for the visit.
---Facility authorized hospice services for resident without resident's responsible party consent.
It was alleged that other parties knew nothing about resident #1 (R1) receiving hospice care. To investigate these allegations, on 02/07/2022 at 10:30am, LPA requested pertinent documents and interviewed the Administrator and other parties. Based on interviews, the other parties were not aware that R1 started receiving hospice services. A record review also shows that the Administrator, Michelle Weisman, signed all hospice related documents in place of the resident's responsible party.
Based on the information revealed during the interviews and record review, the allegation is SUBSTANTIATED at this time. An exit interview was conducted, and a Plan of Correction was reviewed and developed with the Administrator. A copy of this report, LIC 9099-D, and Appeal Rights were discussed and provided to Administrator, whose signature on this form confirm receipt of these documents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

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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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
02/01/2022 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20220201084111

FACILITY NAME:	NEST, THE		FACILITY NUMBER:	197608595
ADMINISTRATOR:	MICHELLE WEISMAN		FACILITY TYPE:	740
ADDRESS:	4100 HAYVENHURST AVENUE		TELEPHONE:	(818) 990-6896
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	6	CENSUS: 6	DATE:	04/04/2022
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:			TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility would not disclose hospice agency information with resident's responsible party.

INVESTIGATION FINDINGS:

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

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA met with Administrator and explained the reason for the visit.
---Facility would not disclose hospice agency information with resident's responsible party.
It was alleged that the facility didn’t want to share the hospice agency name with other parties. To investigate these allegations, on 02/15/2022 at approximately 2:30pm, LPA interviewed the Administrator and other parties and it was determined that the Administrator did not withhold the name of the hospice agency.

Based on the interviews, there is not enough informion to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

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-20220201084111

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: NEST, THE	FACILITY NUMBER: 197608595
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/07/2022 Section Cited CCR 87633(a)(3)	1 2 3 4 5 6 7	87633(a) The licensee shall be permitted to.. retain residents who have been diagnosed as terminally ill by.. physician (3) Hospice agency services are contracted for by each terminally ill resident.. individually, or the resident’s.. Health Care Surrogate Decision Maker if the resident.. is incapacitated,	1 2 3 4 5 6 7	The Administrator will review Section 87633 and will inform in writing explaining how they will assure to follow Title 22 Regulations regarding hospice care.
	8 9 10 11 12 13 14	not by the licensee on behalf of a resident.. This requirement is not met as evidenced by: Based on record review, the hospice service was not agreed to by the resident/resident’s decision maker. This poses a potential personal rights violation to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

LIC9099 (FAS) - (06/04)

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