197608694-3-28-2023-29-AS-DPEA-CSD343-20230531175429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608694
Report Date: 03/28/2023
Date Signed: 03/28/2023 04:05:56 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2022 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20221108141413

FACILITY NAME:	VILLAGE AT SHERMAN OAKS, THE		FACILITY NUMBER:	197608694
ADMINISTRATOR:	DANA ANDERSON		FACILITY TYPE:	740
ADDRESS:	5450 VESPER AVE		TELEPHONE:	(818) 994-7900
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY:	179	CENSUS: 78	DATE:	03/28/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ada Navarette - Assisted Living Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff neglected Resident #1 (R1) by failing to obtain timely medical attention after a fall

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Brian Balisi and Esther Cortez conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPAs met with Ada Navarette and explained the reason for the visit.

On 11/08/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that staff neglected Resident #1 (R1) by failing to obtain timely medical attention after a fall. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Christine Ferris.

On 11/10/2022, between 11:20am and 2:30pm, Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit. LPA Balisi met with the Director of Assisted Living Ada Navarette and explained the reason for the visit. At approximately 11:20am, the LPA conducted a physical plant tour, interviewed staff and obtained copies of pertinent documents relevant to the investigation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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 8

Control Number 29-AS-20221108141413

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 03/28/2023

NARRATIVE

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Continued 9099

Investigator Ferris conducted interviews on 12/08/2022 with the Executive Director/Administrator and residents; on 12/19/2022, with R1’s resident representatives and staff; and on 01/03/2023, with the Director of Assisted Living and staff. In addition, the investigator reviewed Sherman Oaks Hospital medical records, Gem Home Health records, and facility file documents related to R1.

R1’s Physician Report, dated 05/17/2022, stated R1 was diagnosed with mild cognitive impairment, history of skin breakdown, able to follow directions, communicate needs, requires assistance with transfers and is non-ambulatory. According to R1’s resident appraisal, dated 06/13/2022, R1 required assistance with transfers and bathing, has limitations with ambulation, uses a wheelchair, and is non-ambulatory. Skin integrity was listed as a stage 2 of left side of buttock currently on home health for treatment. The Assessment and Service Plan listed R1’s move in date as 06/13/2022 and documented that R1 had a healed wound in sacrum, uses home health aide for healed wound to prevent skin breakdown.

The investigation revealed that on 08/08/2022, R1 experienced a fall during their shower. The nurse asked Staff #1 (S1) to assist with the shower. R1 did not want a shower but the nurse and S1 encouraged R1 to shower. S1 assisted R1 with the shower using a shower chair. Near the end of the shower, S1 asked R1 to stand up and hold onto the shower bars so S1 could rinse off the soap from R1’s body. R1 stood up and held onto the shower bars when R1 slipped and fell on their buttocks. R1 yelled “I broke my hip!”. The nurse was present in the bathroom the entire time and witnessed the incident. R1 was able to get up with assistance of staff and completed their shower.

At the time of the incident, R1 denied paramedic assessment, complained of back pain, describing the pain as “low” (3 out of 10) on the pain scale, and requested Tylenol. The Director of Assisted Living was notified and advised staff to monitor R1 for any changes in condition. R1’s primary care physician and resident representatives were notified of R1’s fall.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 29-AS-20221108141413

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 03/28/2023

NARRATIVE

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Continued 9099-C

On 08/09/2022, at approximately 5:00am, R1 called for staff assistance as they were experiencing left-side hip pain. 9-1-1 was called and R1 was transported to Sherman Oaks Hospital. R1 presented with severe left hip pain, a sacral deep tissue injury (DTI) red with a scab, an arm skin tear, and a thumb laceration. Orthopedic surgery was consulted and R1 was diagnosed with a Femoral neck fracture (hip fracture). A left hip hemiarthroplasty was performed.

The Department’s investigation provided sufficient evidence to substantiate neglect/lack of supervision against the facility staff. After R1 fell in the shower, S1 heard R1 say they broke their hip and the nurse heard R1 immediately complain of back pain. In addition, the nurse communicated via a report to R1’s primary care physician stating R1 was complaining of hip and back pain and provided R1 with Tylenol. The Director of Assisted Living stated they were advised of the fall and R1’s complaint of pain and told the nurse that if R1 complained of pain “again” to call 9-1-1. Based on the information obtained there was sufficient evidence that R1 complained of hip and back pain immediately after the fall and 9-1-1 should have been called, therefore, the allegation “Staff neglected Resident #1 (R1) by failing to obtain timely medical attention after a fall” is deemed substantiated at this time.

A $500 immediate civil penalty is assessed today.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 29-AS-20221108141413

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 03/29/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465(a)(1) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care ...appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to submit plan how you will ensure residents receive timely medical care and submit to CCL via email by EOD 03/29/2023.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above. Staff did not obtain timely medical attention for R1 when R1 fell and complained of hip and back pain, which posed an immediate health and safety risk 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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 8

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
11/08/2022 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20221108141413

FACILITY NAME:	VILLAGE AT SHERMAN OAKS, THE		FACILITY NUMBER:	197608694
ADMINISTRATOR:	DANA ANDERSON		FACILITY TYPE:	740
ADDRESS:	5450 VESPER AVE		TELEPHONE:	(818) 994-7900
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY:	179	CENSUS: 78	DATE:	03/28/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ada Navarette - Assisted Living Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff pushed Resident #1 (R1) while in the shower resulting in a fractured left hip
Staff neglected Resident #1 (R1) resulting in a pressure injury
Facility staff did not fix resident's toilet in a timely manner
Facility staff did not maintain resident’s hygiene
Facility staff did not keep resident’s bathroom free from pests
Facility staff did not provide assistance to resident in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)’s Brian Balisi and Esther Cortez conducted a subsequent complaint visit to deliver findings and continue investigation for the above allegations. During today’s visit, LPA met with Ada Navarette and explained the reason for the visit.

On 11/08/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that staff pushed Resident #1 (R1) while in the shower resulting in a fractured left hip and staff neglected Resident #1 (R1) resulting in a pressure injury. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Christine Ferris.

On 11/10/2022, between 11:20am and 2:30pm, Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit. LPA Balisi met with the Director of Assisted Living Ada Navarette and explained the reason for the visit. At approximately 11:20am, the LPA conducted a physical plant tour, interviewed staff and obtained copies of pertinent documents relevant to the investigation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 29-AS-20221108141413

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 03/28/2023

NARRATIVE

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Continued from 9099-A

Investigator Ferris conducted interviews on 12/08/2022 with the Executive Director/Administrator and residents; on 12/19/2022, with R1’s resident representatives and staff; and on 01/03/2023, with the Director of Assisted Living and staff. In addition, the investigator reviewed Sherman Oaks Hospital medical records, Gem Home Health records, and facility file documents related to R1.

R1’s Physician Report, dated 05/17/2022, stated R1 was diagnosed with mild cognitive impairment, history of skin breakdown, able to follow directions, communicate needs, requires assistance with transfers and is non-ambulatory. According to R1’s resident appraisal, dated 06/13/2022, R1 required assistance with transfers and bathing, has limitations with ambulation, uses a wheelchair, and is non-ambulatory. Skin integrity was listed as a stage 2 of left side of buttock currently on home health for treatment. The Assessment and Service Plan listed R1’s move in date as 06/13/2022 and documented that R1 had a healed wound in sacrum, uses home health aide for healed wound to prevent skin breakdown. The physician orders, dated 06/15/2022, listed R1’s pressure injury stage 3 wound as healed and discontinued wound treatment. On 07/21/2022, physician orders indicate R1 still has a stage 2 pressure injury to right buttock, continuous wound care needed, and home health was recertified for the care period of 07/23/2022 to 09/20/2022.

The investigation revealed that on 08/08/2022, R1 experienced a fall during their shower. The nurse asked Staff #1 (S1) to assist with the shower. R1 did not want a shower but the nurse and S1 encouraged R1 to shower. S1 assisted R1 with the shower using a shower chair. Near the end of the shower, S1 asked R1 to stand up and hold onto the shower bars so S1 could rinse off the soap from R1’s body. R1 stood up and held onto the shower bars when R1 slipped and fell on their buttocks. R1 yelled “I broke my hip!”. The nurse was present in the bathroom the entire time and witnessed the incident. R1 was able to get up with assistance of staff and completed their shower. At the time of the incident, R1 denied paramedic assessment, complained of back pain, describing the pain as “low” (3 out of 10) on the pain scale, and requested Tylenol. The Director of Assisted Living was notified and advised staff to monitor R1 for any changes in condition. R1’s primary care physician and resident representatives were notified of R1’s fall. On 08/09/2022, at approximately 5:00am, R1 called for staff assistance as they were experiencing left-side hip pain. 9-1-1 was called and R1 was transported to Sherman Oaks Hospital. R1 presented with severe left hip pain, a sacral deep tissue injury (DTI) red with a scab, an arm skin tear, and a thumb laceration. Orthopedic surgery was consulted and R1 was diagnosed with a Femoral neck fracture (hip fracture). A left hip hemiarthroplasty was performed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 29-AS-20221108141413

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 03/28/2023

NARRATIVE

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On the allegation “Staff pushed Resident #1 (R1) while in the shower resulting in a fractured left hip”. The information obtained during the course of the investigation did not provide sufficient evidence to substantiate physical abuse against the facility staff. R1 was diagnosed with mild cognitive impairment and R1’s representatives both advised R1’s memory was not reliable. The staff who showered R1 denied pushing R1 and consistently stated R1 slipped and fell. The Department does not have sufficient evidence to substantiate R1 was pushed, therefore, the allegation is deemed unsubstantiated at this time.

On the allegation “Staff neglected Resident #1 (R1) resulting in a pressure injury”. The information obtained during the course of the investigation did not provide sufficient evidence to substantiate neglect/lack of supervision against the facility staff. R1 received wound care from home health and the last report dated 07/21/2022, stated R1 had a stage 2 pressure injury to their right buttock. Upon admittance to the hospital on 08/09/2022, R1 was diagnosed with an intact deep tissue injury (DTI) to their sacrum described as redness with a scab. The Department does not have sufficient evidence to substantiate staff neglected R1 resulting in a pressure injury. Therefore, the allegation is deemed unsubstantiated at this time.

On the allegation “Facility staff did not fix resident’s toilet in a timely manner”. The information obtained during the course of the investigation did not provide sufficient evidence to substantiate that staff left resident’s toilet in disrepair for extended periods of time. LPA records review of facility maintenance log revealed between 08/01/2022 – 08/31/2022, there were (10) maintenance requests for clogged toilets or toilets not working properly and each request was repaired on the same day it was requested. Records review further revealed that (5) work orders were made to repair R1’s toilet. . Each request was completed on the same day. LPA’s interview with (10) residents revealed that all residents have sent in a maintenance request for repair and each have not experienced long wait times after a request was made. The Department does not have sufficient evidence to substantiate that staff left resident’s toilet in disrepair for extended periods of time. Therefore, the allegation is deemed unsubstantiated at this time.

On the allegation that “Facility staff did not maintain resident’s hygiene”. The information obtained during the course of the investigation did not provide sufficient evidence to substantiate that staff did not shower R1 for multiple days. LPA’s records review and interview with Assisted Living Director and seven (7) staff revealed R1 was scheduled to be showered twice a week and each have never observed R1 go more than (1) day without a shower.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 29-AS-20221108141413

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 03/28/2023

NARRATIVE

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Continued from 9099-C
LPA interview with twelve (12) residents who receive assistance with showers revealed that each resident stated they have never gone multiple days without a shower. The department does not have sufficient evidence to substantiate that staff did not shower R1 for multiple days. Therefore, the allegation is deemed unsubstantiated at this time.

On the allegation “Facility staff did not keep resident’s bathroom free from pests”. The information obtained during the course of the investigation did not provide sufficient evidence to substantiate that facility did not make any attempts to keep resident’s rooms free from pests. LPA's records review and interview with Maintenance Director revealed between 08/01/2022 – 08/31/2022, the facility was not able to avoid a seasonal infestation of ants in various rooms throughout the facility. Records review and interviews further revealed that the facility had contracted a pest control company visiting twice a month to attempt to be proactive in preventing infestations at the facility. LPA’s interview with twelve (12 ) residents revealed that (4) out of the (12) residents reported to the facility they had ants in their room and all (4) stated the issue was resolved in the same day. Six (6) out of the twelve (12) residents interviewed stated they have not observed ants in their room at this time. The Department does not have sufficient evidence to substantiate that facility did not make any attempts to keep resident’s rooms free from pests. Therefore, the allegation is deemed unsubstantiated at this time.

On the allegation “Facility staff did not provide assistance to resident in a timely manner”. The information obtained during the course of the investigation did not provide sufficient evidence to substantiate that R1 had to wait one hour after calling for assistance. LPA's conducted a random inspection of four (4) pendants and staff responded within a reasonable time. The facility's expectation for response time is 10 to 15 mins. LPA's records review of pendant summary log for R1 revealed the average wait time for R1 to receive a response from staff was 3 mins and 53s. LPA's observed an outstanding wait time of 46 min on 08/09/2022 and Interview with Assisted Living Director revealed it was due to staff focusing on the well-being of R1 and had forgot to reset the pendant. The Average response time for all residents was 9m 42s. Interviews with seven (7) out of twelve (12) residents, revealed that they are satisfied with the staff response time when they need assistance. The Department does not have sufficient evidence to substantiate that R1 had to wait hours after calling for assistance. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted, a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 8