197608711-10-5-2020-31-AS-CHAS-C35SGZ-20210518135245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608711
Report Date: 10/01/2020
Date Signed: 10/05/2020 09:21:40 AM

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
09/19/2019 and conducted by Evaluator Martina Berry

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20190919121908

FACILITY NAME:	FOOTHILL RETIREMENT CARE HOME		FACILITY NUMBER:	197608711
ADMINISTRATOR:	CARLOS LARA		FACILITY TYPE:	740
ADDRESS:	6720 SAINT ESTEBAN STREET		TELEPHONE:	(818) 353-3350
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	72	CENSUS: 63	DATE:	10/01/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jina Maleksarkissians		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1. Resident#1 requires a higher level of care.

2. Staff is not providing appropriate care and supervision to Resident#1 resulting to multiple falls.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Martina Berry conducted a subsequent complaint investigation in response to the allegations above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually via Zoom at 1:30 PM. The LPA met with Administrator Jina Maleksarkissians and explained the reason for the visit.

Allegation #1: Resident#1 requires a higher level of care.

It was alleged that Resident (R1) requires a higher level of care. A review of R1’s file was conducted on 7/15/20 to determine R1’s level of need. Needs identified in Medical Records, Physician’s Report, and Needs and Services Plan do not indicate that R1’s needs are at a level that cannot be met by an RCFE. Staff interviews were conducted 9/24/19, 4/9/20, and 8/12/20. According to staff interviews, R1’s needs are effectively managed by two staff when R1 accepts help.
(Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina Berry	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

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 2

Control Number 31-AS-20190919121908

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: FOOTHILL RETIREMENT CARE HOME	FACILITY NUMBER: 197608711
	VISIT DATE: 10/01/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

An interview with a family member of R1 on 9/24/19 revealed that the family member actively participates in R1’s care, working alongside the staff. The family member and staff work collaboratively to plan for R1's care. The family member has no concerns about the level of care provided at the facility. Based on the information obtained from Record Review and interviews, this allegation is unsubstantiated.

Allegation #2: Staff is not providing appropriate care and supervision to Resident #1 resulting to multiple falls.

It was alleged that staff is not providing appropriate care and supervision resulting in multiple falls. A review of the facility file was conducted on 7/15/20. Incident reports show calls made to 911 by staff and R1 to respond to falls. R1 was interviewed on 9/24/19 regarding this allegation. R1 reported that staff is helpful and is available to help at any time. According to R1, two staff respond to assist when needed. R1’s family member was interviewed on 9/24/19. Family member stated that R1 prefers to perform tasks independently but requires assistance. Family member stated that R1 is impatient and calls for other assistance if staff does not respond immediately. The family member has no concerns about the care and supervision provided to R1 at the facility. According to the facility administrator’s interview on 9/24/19, R1 has a medical condition requiring more activity to build strength and improve overall health. R1 was reappraised to include more physical activity. Two staff are dedicated to R1 to assist with daily needs. The information obtained from file review and interviews does not support this allegation. Therefore, the allegation is unsubstantiated.

An exit interview was conducted with Administrator Jina Maleksarkissians. A copy of this report was provided via email for signature.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina Berry	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2