197608711-2-8-2022-31-AS-EMIR-CBR2L4-20220217162857

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608711
Report Date: 09/30/2021
Date Signed: 02/08/2022 01:42:04 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2020 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20200312132701

FACILITY NAME:	FOOTHILL RETIREMENT CARE HOME		FACILITY NUMBER:	197608711
ADMINISTRATOR:	JINA MALEKSARKISSIANS		FACILITY TYPE:	740
ADDRESS:	6720 SAINT ESTEBAN STREET		TELEPHONE:	(818) 353-3350
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	72	CENSUS: 42	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Roy Manasan		TIME COMPLETED:	09:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident has multiple pressure wounds.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegation.

As part of this investigation, on 3/13/20 LPA interviewed a staff member and collected relevant documents from Resident 1's (R1's) file. On 9/30/21 LPA interviewed the facility administrator and reviewed and obtained copies of additional client records.
Allegation #1, that "Resident has multiple pressure wounds," has been unsubstantiated based on the records reviewed and interviews conducted. LPA confirmed via the complainant that R1 was admitted to the hospital on 3/10/20 with multiple stage 1 and stage 2 pressure injuries. Staff 1 (S1) stated on 3/13/20 that R1 was receiving Home Health services for wound care, which LPA confirmed with a file review on 9/30/21 at 9:00a.m. at the facility. This is an allowable heatlh condition under Title 22 sections 87611 and 87631.
Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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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