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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608711
Report Date: 01/14/2022
Date Signed: 01/14/2022 01:38:02 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
08/13/2021 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20210813164945
FACILITY NAME:FOOTHILL RETIREMENT CARE HOMEFACILITY NUMBER:
197608711
ADMINISTRATOR:JINA MALEKSARKISSIANSFACILITY TYPE:
740
ADDRESS:6720 SAINT ESTEBAN STREETTELEPHONE:
(818) 353-3350
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:72CENSUS: 40DATE:
01/14/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Emerald Caceres TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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facility failed to provide adequate care and supervision
lack of care and supervision resulted in client injury
INVESTIGATION FINDINGS:
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During this investigation, Special Investigator Patterson reviewed resident and facility records obtained from the facility on 8/16/21; reviewed records obtained from Providence St. Joseph Medical Records on 10/11/21; interviewed 2 residents, 2 staff and the administrator on 11/4/21; interviewed the complainant on 11/5/21; interviewed a relevant witness on 11/15/21; interviewed two staff on 11/18/21; interviewed two staff and the administrator on 11/19/21.
The allegation “facility failed to provide adequate care and supervision” has been substantiated based on the records reviewed and interviews conducted. Facility and hospital records show that on 8/1/21 Resident 1 (R1) fell and sustained a fractured wrist and rib. The investigation revealed that R1 had previously fallen in July 2019 and on 10/29/2020, and that no new written appraisal of R1’s needs and services had been conducted following the 10/29/20 fall which means that appropriate fall prevention measures were potentially overlooked and not implemented.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
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 3
Control Number 31-AS-20210813164945
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: 01/14/2022
NARRATIVE
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The allegation that “lack of care and supervision resulted in client injury.” Has been substantiated based on the interviews conducted and records reviewed. Facility and hospital records show that on 8/1/21 R1 fell and sustained a fractured wrist and rib. Investigator Patterson was able to interview 1/2 of the staff working that night and was informed that due to inadequate staffing on the night in question, R1 repeatedly left their room in the middle of the night looking for assistance which likely contributed to their fall and subsequent injuries.

Report reviewed, signed and delivered. Exit interview conducted, appeal rights issued, deficiencies cited on 9099(D) page. Immediate Civil Penalty of $500 assessed. The administrator was informed that an enhanced civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or(f).

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20210813164945
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2022
Section Cited
CCR
87466
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87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or...
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Administrator will provide a signed statement confirming that they have reviewed all resident care plans, as well as all recent incident reports, to ensure that resident needs are appropriately documented.
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This requirement is not met as evidenced by:

Based on records reviewd and interviews conducted, the facility did not ensure that R1's condition was regularly observed/ documented and that appropriate assistance was provied which poses an immediate risk to residents.
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Type A
01/18/2022
Section Cited
CCR
87464(f)(4)
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87464 (f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Support
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Administrator will provide a copy of the facility's staff schedule along with verification that all staff have been trained on current resident needs as documented in the updated assesments conducted in the above plan of correction.
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This requirement is not met as evidenced by:

Based on interviews and records reviewed, the facility did not ensure that R1 was receiving an appropriate level of assistance on 8/12/21 when they fell which poses an immediate risk to residents in care.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3