197608768-7-21-2022-31-AS-NGID-CH4PNY-20220808112840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608768
Report Date: 07/21/2022
Date Signed: 07/21/2022 04:52:59 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2022 and conducted by Evaluator Joscelyn Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220407163328

FACILITY NAME:	DEARBORN HOME		FACILITY NUMBER:	197608768
ADMINISTRATOR:	CHARMILEY ANDRES		FACILITY TYPE:	735
ADDRESS:	16513 DEARBORN STREET		TELEPHONE:	(626) 926-7186
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	4	CENSUS: 4	DATE:	07/21/2022
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Loramay Pana		TIME COMPLETED:	11:30 PM

ALLEGATION(S):

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Resident sustained unexplained fractures while in care.

INVESTIGATION FINDINGS:

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On 07/21/22 Licensing Program Analyst (LPA) Joscelyn Martinez conducted a subsequent complaint visit for the purpose of issuing the completed investigative report conducted by CCL’s Investigative Branch (IB). On 04/07/22, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s, Investigation Branch as an assignment to obtain relevant information. The complaint was accepted by CCL IB and was assigned to investigator Christine Ferris and Heidy Bendana. LPA met with Loramay Pana and the purpose of the visit was explained.

On 04/08/22 LPA Reed conducted an unannounced visit and collected relevant documents pertaining to the allegation. IB Investigator Ferris and Bendana conducted a visit on 04/26/22 and conducted a file review for R1. IB Investigators conducted interviews with four (4) caregivers, administrator, R1, witness, two (2) residents, and R1’s physician team.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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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Control Number 31-AS-20220407163328

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: DEARBORN HOME	FACILITY NUMBER: 197608768
	VISIT DATE: 07/21/2022

NARRATIVE

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It is alleged that R1 sustained unexplained fractures while in care. Investigation revealed that on 03/28/22 R1 pushed against a positioning tray that R1 uses causing it to fall of the wheelchair and onto R1’s legs and feet which caused the fractures. The positioning tray broke during the time it fell. Positioning tray is specific for R1’s wheelchair and R1 has used the tray from the start of admission to the facility on 01/27/2015. Staff did not observe any discomfort in R1 on 03/29/22 and verbally informed staff to keep close attention for any change of behavior in R1. On 03/29/22 during the night R1’s right foot was observed to be swollen by staff and R1’s big toe had discoloration. R1’s physician informed staff to send pictures of R1’s injuries. On 04/03/22 R1’s podiatrist conducted a home consultation and advised staff to continue with R1’s primary physician’s plan to have an ultrasound conducted on R1’s legs. On 04/06/22 staff took R1 to see R1’s primary physician and was informed to go to the hospital for further evaluation. Emergency room diagnosed R1 with right and left ankle fractures. This incident was reported to CDSS on 03/29/22. According to the medical personnel, there is no concern for neglect/lack for R1’s safety or well-being in the facility.

Therefore, due to a lack of supporting evidence the allegation, “Resident sustained unexplained fractures while in care”, is deemed Unsubstantiated.

No deficiencies cited. Exit interview conducted. Report signed and delivered. Appeals right delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC9099 (FAS) - (06/04)

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