197608694-1-13-2022-29-AS-DPEA-CB7SRY-20220131130703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608694
Report Date: 01/13/2022
Date Signed: 01/13/2022 01:19:58 PM

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
05/11/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210511101014

FACILITY NAME:	VILLAGE AT SHERMAN OAKS, THE		FACILITY NUMBER:	197608694
ADMINISTRATOR:	PAMELA MUNDAY		FACILITY TYPE:	740
ADDRESS:	5450 VESPER AVE		TELEPHONE:	(818) 994-7900
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY:	100	CENSUS: 57	DATE:	01/13/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Michele Johnson - Executive Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Physical abuse resulting in injury(ies)

Due to faciltiy lack of care and supervision, resident sustained injuries

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver findings for the above allegations. The initial complaint visit was conducted on 05/12/2021 and a subsequent complaint visit was conducted on 09/03/2021 by LPA Brian Balisi. During today’s visit, LPA Balisi met with Michele Johnson and explained the reason for the visit.

On 05/11/2021, the Department received a complaint regarding allegations of Neglect/Lack of Supervision and physical abuse. It was alleged that facility employees neglected or failed to provide an appropriate level of supervision which resulted in R1 sustaining a severe skin tear on the back of left hand as well as a scrape to forehead and an injury to lip. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real.

On 05/12/2021, at 9:45 a.m., LPA Balisi conducted the initial complaint visit and met with Elizabeth Ham, Director of Assisted Living.

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: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

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-20210511101014

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: 01/13/2022

NARRATIVE

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Continued from 9099

Between 10:00 a.m. and 12:00 p.m., LPA Balisi conducted a physical plant tour and obtained copies of pertinent documents relevant to the investigation. On 09/03/2021, from 12:45 p.m. to 1:30 p.m., LPA Balisi conducted a subsequent complaint visit to review and obtain copies of additional documents relevant to the investigation.

Investigator Real conducted interviews with the Assisted Living Director on 06/15/2021; with R1’s private caregiver on 07/16/2021; with Hospice employees on 08/04/2021 and 08/13/2021; with facility employees on 08/17/2021 and 08/19/2021; with former facility employees on 09/07/2021, 09/10/2021, and 09/28/2021; and with residents on 09/07/2021. On 12/13/2021, Investigator Real conducted additional interviews with two (2) family members of R1.

Investigator Real reviewed the facility progress notes for R1. The progress note dated 04/05/2021 at 7:28 a.m. indicated R1 had a skin tear on left hand. R1’s hospice agency was notified along with R1’s family member. The progress note dated 04/16/2021 at 10:45 a.m. indicated R1’s private caregiver reported to a facility staff #1 (S1) that R1 had a bloody lip. S1 checked R1’s lip and there was no trauma to the area. R1’s lips were dry and chapped with a bead sized amount of blood. S1 cleaned the area and applied lotion. Neither S1 nor the private caregiver noted any other areas of concern on R1’s face or head at that time. A short time later, R1’s private caregiver and a hospice employee showered R1 and observed a bump on R1’s forehead. The skin at the center of the bump was open and it appeared to be an abrasion. S1 reported changing R1 earlier and did not see any bumps on R1’s head

Investigator Real reviewed Oakhurst Hospice agency records for R1. The hospice notes for 05/05/2021 indicated that the hospice nurse observed R1 had a skin tear on the back of left hand that had been bandaged. The notes for 04/16/2021 indicated R1 had a small abrasion on forehead as well on one on upper lip and the cause was unknown. There were no abuse or neglect concerns noted in the hospice records.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20210511101014

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: 01/13/2022

NARRATIVE

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Continued from 9099-C

On the allegation: Neglect/Lack of Care and Supervision – Facility employees failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) sustaining a skin tear on hand, a scrape/bump on forehead and a small injury to lip. Investigator Real conducted interviews with R1’s private caregiver, hospice employees, facility employees, residents and family members. None of the persons interviewed reported knowing how R1’s injuries occurred, and none suspected any abuse or neglect. R1’s private caregiver discovered the injuries and denied harming or accidentally causing the injuries. R1’s private caregiver had no abuse or neglect concerns regarding the facility employees and suspected the injuries were accidental and may have occurred while transferring R1 or changing R1’s diapers. A hospice nurse who regularly saw R1 in the facility reported that R1 had very thin skin and was susceptible to skin tears. The hospice employees had no abuse or neglect concerns regarding the facility employees and felt R1 received good care in the facility. The facility residents had no abuse or neglect concerns and reported the facility employees treat them well. The facility employees denied the allegation, and none reported knowing how the injuries occurred. R1’s family members have not witnessed or observed any of the facility employees neglect R1. The injuries were discovered at different times, with the skin tear on R1’s hand observed eleven days prior to the discovery of the scrape on R1’s lip. The private caregiver brought a facility employee to check R1’s lip and neither of them saw any injury on R1’s forehead at that time. The forehead injury was not discovered until a little later in the morning while the private caregiver and a hospice employee were giving R1 a shower. Prior to the shower, the private caregiver and the hospice employee transferred R1 out of bed using a Hoyer lift and then moved R1 into the shower via a wheelchair. It seems more likely than not that the forehead injury occurred at some point when the private caregiver and the hospice employee transferred R1 out of bed with the Hoyer lift. The information and evidence obtained during the investigation did not sufficiently support the allegation, therefore the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 29-AS-20210511101014

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: 01/13/2022

NARRATIVE

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Continued from 9099-C

On the allegation: Physical Abuse – R1 was physically abused by an unknown suspect which resulted in a skin tear on hand, a scrape/bump on forehead and a small injury to lip. Investigator Real conducted interviews with R1’s private caregiver, hospice employees, facility employees, residents and family members. None of the persons interviewed reported knowing how R1’s injuries occurred. R1’s private caregiver denied harming R1 and had no abuse or neglect concerns regarding the facility employees. The hospice employees and residents had no abuse or neglect concerns. The facility employees denied the allegation. R1’s family members did not witness any of the facility employees harm or injure R1. R1’s hospice records were obtained, and no abuse or neglect concerns were noted in the records. The information and evidence obtained during the investigation did not sufficiently support the allegation, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview, copy of report given.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4