197608603-10-27-2022-29-AS-JAPL-CKYM5F-20221108081816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608603
Report Date: 10/26/2022
Date Signed: 10/27/2022 12:24:56 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
05/27/2022 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20220527104820

FACILITY NAME:	LIVEWELL RESIDENTIAL CARE HOME		FACILITY NUMBER:	197608603
ADMINISTRATOR:	FRANCIS MARTIR		FACILITY TYPE:	740
ADDRESS:	14315 VALERIO STREET		TELEPHONE:	(818) 989-1073
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 5	DATE:	10/26/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Lorna Montemayor		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Questionable Death
The administrator failed to ensure that Resident #1 (R1) received their medication, Invega (injectable), which was prescribed for once a month.

INVESTIGATION FINDINGS:

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On 10/26/2022, Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver final findings for the above allegations. The initial complaint visit was conducted on 06/02/2022 by LPA Salia Walker. During today’s visit, LPA Urena was greeted by facility staff, and explained the reason for the visit. The staff contacted the Administrator. The LPA spoke with Administrator Francis Martir on the phone and the reason for the visit was explained. Ms. Martir could not meet the LPA at the facility, and asked that staff to sign today’s report.
On 05/04/2022, from 5:02 p.m. to 6:00 p.m., Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Case Management - Incident visit to the facility to follow up on the reported death of Resident #1 (R1). Upon arrival, LPA Chochian was greeted by facility staff. The staff contacted the Administrator. The LPA spoke with Administrator Francis Martir at approximately 5:10 p.m. and the reason for the visit was explained. Ms. Martir could not meet the LPA at the facility and asked that staff assist LPA with the visit. The purpose of the visit was regarding the death of R1, deceased at Valley Presbyterian Hospital on 05/04/2022.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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 29-AS-20220527104820

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: LIVEWELL RESIDENTIAL CARE HOME	FACILITY NUMBER: 197608603
	VISIT DATE: 10/26/2022

NARRATIVE

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The Administrator called the Regional Office and reported that R1 was transported to the hospital upon staff finding R1 on the floor in the restroom unresponsive. During the visit, the LPA conducted a tour of the facility at 5:15 p.m. with staff. LPA Chochian could not review the resident’s file as the Administrator took the file to fax requested documents to the Department. A brief interview was conducted with facility staff and the Administrator. The Administrator was informed prior to issuing a final licensing report that further investigation was needed. The case was referred to Community Care Licensing Investigations Branch (IB) and was assigned to Investigator Peter Zertuche.

On 05/27/2022, the Department received a complaint regarding an allegation of a Questionable Death related to the 05/04/2022 death of R1.

On 06/02/2022, from 10:15 a.m. to 2:45 p.m., Licensing Program Analyst (LPA) Salia Walker arrived unannounced for the initial complaint inspection for the above allegation. LPA Walker met with Administrator Francis Martir at 10:47 a.m. and explained the reason for the visit. During the visit, the LPA conducted a physical plant tour with staff at 10:28 a.m. From 10:49 a.m. until 11:11 a.m., the LPA conducted an interview with the Administrator. From 11:11 a.m. until 11:40 a.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 11:44 a.m. until 1:00 p.m., the LPA along with the Administrator reviewed medications for one (1) out of five (5) residents. The Administrator was informed that further investigation was needed.

Investigator Zertuche conducted interviews on 05/10/2022, from approximately 9:45 a.m. to 11:00 a.m., with facility staff, the Administrator, and residents; on 06/13/2022, from approximately 3:00 p.m. to 4:00 p.m., with R1’s representative and R1’s Doctor; and on 06/30/2022, at approximately 1:00 p.m., with the Medical Examiner, Los Angeles Coroner’s Office. Additionally, Investigator Zertuche obtained and reviewed copies of R1’s facility records, Valley Presbyterian Hospital medical records, and Los Angeles City Fire Department (LAFD) paramedics report. Per contact with the Los Angeles Police Department (LAPD) on 05/10/2022, at approximately 8:30 a.m., there was no law enforcement involved in this case. On 06/22/2022, at approximately 1:30 p.m., Investigator Zertuche contacted the Long-Term Care Ombudsman’s (LTCO) office but was unable to obtain any information regarding their case due to lack of consent to discuss the incident.
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SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220527104820

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: LIVEWELL RESIDENTIAL CARE HOME	FACILITY NUMBER: 197608603
	VISIT DATE: 10/26/2022

NARRATIVE

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Records reflect that R1 was independent; able to care for self, including bathing and toileting needs. The Physician Report, dated 10/10/2021, revealed that R1 was able to leave the facility unassisted. R1 was diagnosed with diabetes along with schizophrenia and mental disorders with no recent episodes of aggression.

On the allegation: Questionable Death – Resident was hospitalized for an unwitnessed fall after being left unsupervised in the bathroom which resulted in death. On 05/04/2022, at approximately 12:00 p.m., residents were in the kitchen eating lunch. R1 had just finished lunch and left the kitchen area. After several minutes, staff noticed R1 was not around, so staff went looking for R1. R1 was not in R1’s room. Staff checked the front and back areas of the facility as R1 normally goes out to smoke, but R1 was not there. Staff noticed one of the bathrooms with the door closed. Staff knocked, but there was no answer. Staff opened the door and found R1 lying on the right side of the toilet. R1 was unresponsive, 9-1-1 was called, and staff began CPR, instructed by the 9-1-1 operator until the paramedics arrived. According to the paramedics, R1 was found in the bathroom in cardiac arrest. R1 was found with two (2) small pieces (around the size of 1 inch by 2-inch round pieces) of paper towels lodged in throat. The paramedics were able to retrieve the debris with forceps and the patient was intubated while being transported to the hospital. While at the hospital R1 passed away. The Medical Examiner confirmed the cause of death was airway obstruction, but the manner of death was undetermined, and the case was closed. The Medical Examiner denied anything suspicious about the death and felt it may have been an accident or suicide.

Throughout the course of the investigation, the facility staff and residents described R1 as an independent resident who was able to use the restroom on their own which was verified by the Doctor and R1’s representative who had no concerns regarding the care provided by the facility who had no indication that R1 was going to self-harm. After being found by staff members in the restroom, 9-1-1 was immediately contacted and CPR was initiated. There was no police involvement in this case and the Coroner’s office had no concerns of suspicious activity. There was insufficient evidence to support the allegation, therefore the allegation Questionable Death - Resident was hospitalized for an unwitnessed fall after being left unsupervised in the bathroom which resulted in death is deemed Unsubstantiated at this time.

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SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220527104820

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: LIVEWELL RESIDENTIAL CARE HOME	FACILITY NUMBER: 197608603
	VISIT DATE: 10/26/2022

NARRATIVE

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On the allegation: The administrator failed to ensure that Resident #1 (R1) received their medication, Invega (injectable), which was prescribed for once a month - On 08/11/2022, LPA Walker contacted the physician obtained through the record review. The physician stated that they had not been R1’s primary physician since R1 left their care, and was admitted to the Livewell Residential Care facility. Furthermore, the physician stated that R1 was to be seen by their primary physician, and reassess the need for the medications previously prescribed to R1. On 10/25/2022, LPA Urena interviewed the physician, and reviewed medical documents for R1. The physician reiterated the information provided previously to LPA Walker. Record review revealed that R1 was prescribed Invega while they were staying at the congregate home. The physician added that once the R1 left the congregate home, they were no longer under the physician's care, and the medication may have change after R1 left. Record review revealed that R1 was receiving a medication, which treats the same condition as Invega does while under the care of the facility. Additional record review revealed that R1 was receiving the medication as prescribed by the physician at the hospital, which was to be provided to R1 two (2x) times a day. Additionally, record review for R1’s medical history revealed that R1 had had different medications to treat the same condition that Invega was used for. Although R1 did not received the medication Invega (injectable) once a month, R1 was receiving a medication to treat the same condition that Invega treated. Therefore, the allegation that the administrator failed to ensure that R1 received the medication to treat R1’s condition is deemed Unsubstantiated at this time.

Exit interview was conducted. A copy of this report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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