197608694-9-20-2024-29-AS-DPEA-D9HTSA-20240927145850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608694
Report Date: 09/20/2024
Date Signed: 09/20/2024 01:34:53 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
03/19/2024 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20240319161408

FACILITY NAME:	VILLAGE AT SHERMAN OAKS, THE		FACILITY NUMBER:	197608694
ADMINISTRATOR:	GRACE HARTNETT		FACILITY TYPE:	740
ADDRESS:	5450 VESPER AVE		TELEPHONE:	(818) 994-7900
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY:	179	CENSUS: 151	DATE:	09/20/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Grace Hartnett		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision: Staff failed to provide adequate supervision to Resident #1 (R1) resulting in a fall and head injuries.

Staff falsified incident report regarding resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Grace Hartnett and explained the reason for the visit.

On 03/19/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding neglect/ lack of care and supervision. The complaint alleged that staff did not provide adequate supervision to Resident #1 (R1) who was a fall risk by leaving R1 alone in the bathroom, resulting in R1 sustaining a fall causing injuries to head and face. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Laura Garcia.

On 03/20/2024, from 12:30 p.m. to 3:30 p.m., LPA Balisi conducted an unannounced complaint visit. At approximately 1:00 p.m., the LPA conducted a physical plant tour, interviewed staff, and reviewed 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: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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 29-AS-20240319161408

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: 09/20/2024

NARRATIVE

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continued from 9099

On 05/14/2024, at approximately 11:20 a.m., Investigator Garcia conducted interviews with R1’s resident representative; on 05/25/2024, from approximately 11:00 a.m. to 1:30 p.m., with Memory Care Director, Med Tech, and staff; on 07/23/2024, from approximately 3:00 p.m. to 3:30 p.m., with facility physical therapist, Affinity Healthcare Resource Center Director of Nurses, and Resident #2’s (R2’s) resident representative. Investigator Garcia attempted to conduct interviews with the reporting party and facility nurse practitioner on several dates from 03/26/2024 to 07/23/2024, left voice mails, but no contact was made possible. In addition, the investigator reviewed Kaiser medical records and facility file documents related to R1.

According to R1’s Physician Report, dated 12/20/2022, R1’s diagnosis was listed as dementia with behavioral disturbance. Other conditions included confused, disoriented, sundowning, and a fall risk. The report indicated R1 needed assistance with bathing, dressing, grooming and toileting.

The review of the incident report submitted by the facility, indicated on the morning of 09/29/2023, 9:30 a.m., R1 was restless during breakfast, constantly trying to stand up. R1 then requested to go to the bathroom and Staff #1 (S1) assisted R1 to the bathroom. While R1 was sitting on the toilet, S1 turned away from R1 to reach for the wipes, when R1 stood up and fell off the toilet. S1 did not see R1 hit their head but heard a loud thud. Med Tech was notified to assess the injury. R1 sustained discoloration on right side of face and sustained a bump on the back of head. The report further stated R1 was alert and talkative. The Paramedics were called via 911 and R1 was taken to Kaiser Panorama City. R1’s resident representative was notified via phone call. R1’s Primary Care Physician (PCP) was notified via fax, and Kaiser Registered Nurse (RN) from the Geriatrics Department was notified via phone call. The report documented R1 sustained an abrasion to head. R1 returned to the facility the same day with a diagnosis of Urinary Tract Infection (UTI), prescribed antibiotics, and placed on frequent checks

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20240319161408

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: 09/20/2024

NARRATIVE

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continued from 9099-C
The review of the Kaiser medical records revealed R1 arrived at the Emergency Room (ER) on 09/29/2023 at 10:11 a.m., with the chief complaint listed as fall with a cause of injury listed as accidental fall, other diagnosis included bone lesion, left lower leg; UTI; and major vascular neurocognitive disorder, unspecified severity, without behavioral disturbance. The records indicated past medical history of lacunar stroke c/b vascular dementia. The records also noted information provided by R1’s resident representative indicated R1 “has a history of multiple falls, is typically in a wheelchair but likes to get up and walk but has unsteady gait so falls often”. X-rays revealed no acute fracture or malalignment identified, no significant joint disease in the hips. R1 was discharged 09/29/2023 with a diagnosis of UTI.

The information obtained through the Department’s interviews was consistent with the information documented in the incident report and the medical records. The Memory Care Director explained that preventive measures were implemented for R1 due to R1’s “high risks for falls” such as providing R1 with a low-rise bed, security mats, alarms when R1 attempts to get out of bed, constant supervisions, frequent checks, and staff adaptations such as encouraging R1 or transferring R1 to the common areas to maintain direct supervision. In addition, R1’s resident representative confirmed that on the day of the incident 09/29/2023, R1 was in the bathroom being assisted by a caregiver. R1’s resident representative was not able to recall details of the incident, however, advised that the caregivers acted accordingly and immediately rendered first aid while contacting paramedics. R1’s resident representative deemed it accidental and reiterated that they did not have any issues regarding the level of care provided. R1’s resident representative denied ever witnessing any lack of supervision or neglect and denied previously having any complaints or issues that were never addressed by the facility staff members.

Based on the statements and documentation provided, the Department found insufficient evidence to determine if there was negligence or lack of supervision on behalf of the facility.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240319161408

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: 09/20/2024

NARRATIVE

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Continued from 9099-C

Therefore, the allegation of “Neglect/Lack of Care and Supervision: Staff failed to provide adequate supervision to Resident #1 (R1) resulting in a fall and head injuries” is deemed to be Unsubstantiated at this time.

It was reported that "Staff falsified incident report regarding resident in care" as it was alleged that Staff #2 (S2) did not notate that S1 left R1 unsupervised , when R1 fell. Interviews and record reviews revealed that when a fall or any incident affecting a resident’s health and safety occurs, the staff member who witnessed the incident writes a report and gives it to the med tech for review. The report is then reviewed internally by corporate and sent to the Executive Director, who forwards it to the Regional Office and any other agencies that need to be notified about unusual incidents. Interviews with six staff members indicated that they all recalled the same details of the incident that occurred on the morning of September 29, 2023, at 9:30 a.m., which were consistent with what was sent to the Regional Office. All six staff members expressed no concerns about any staff falsifying incident reports at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff falsified incident report regarding resident in care” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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