197608927-9-15-2022-29-AS-JAPL-CK3V9R-20221010161448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608927
Report Date: 09/15/2022
Date Signed: 09/15/2022 12:26:51 PM

Substantiated

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
12/02/2021 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-NP-20211202105836

FACILITY NAME:	JUST LIKE HOME II		FACILITY NUMBER:	197608927
ADMINISTRATOR:	MARAT DAVIDIAN		FACILITY TYPE:	740
ADDRESS:	13524 CHANDLER BLVD.		TELEPHONE:	(818) 769-9955
CITY:	SHERMAN OAKS	STATE:	ZIP CODE:	91423
CAPACITY:	6	CENSUS: 6	DATE:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Marat Davidian		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.
Facility did not seek timely medical treatment for changes in resident's health.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the above allegations. The LPA arrived at the facility at 9:30 a.m. Staff contacted administrator via phone. Administrator arrived at 10:15 a.m. LPA Urena met with the administrator Marat Davidian and explained the reason for the visit.

On 12/2/2021, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial 10-day complaint investigation visit regarding the above allegations. LPA Urena reviewed facility records beginning at 11:45 AM, and conducted an interview with the responsible party for one resident and the administrator between 12:00 p.m. and 12:15 p.m.

Continues on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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 29-NP-20211202105836

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: JUST LIKE HOME II	FACILITY NUMBER: 197608927
	VISIT DATE: 09/15/2022

NARRATIVE

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Resident sustained pressure injuries while in care.
On the allegation of ‘Resident sustained pressure injuries while in care’, it is alleged that Resident #1 (R1) was admitted to the hospital with a wound on their left heel, and a sacral stage four (4) pressure injury. To investigate this allegation, LPA Urena requested hospital records and Home Health Services records for review. On 12/08/2021, the LPA reviewed the hospital records. Hospital wound care consultation records confirmed that R1 was admitted to the Emergency Room (ER) with a sacral stage 4 pressure injury, and a left heel wound. On 07/27/2022, the LPA requested Home Health Care Services (HHCS) records and conducted the record review on 08/05/2022.

On 12/02/2021, at 12:00 p.m., the LPA interviewed the administrator about the allegations. Per the administrator, R1 started receiving Home Health Care Services (HHCS) in June 2021 due to a surgical wound. At 12:06 p.m., the LPA interviewed the Responsible Persons (RP) for R1 about the physical condition of R1. The RP reported that they knew a nurse was providing care to R1 for a surgical wound but was not aware of the pressure injury. On 07/27/2022, the LPA interviewed representatives from the HHCS agency about the care provided to R1, and the communication with the facility’s staff in regard to R1’s condition. Per the HHCS representatives, services were provided to R1 from 6/30/2021 to 11/26/2021. Services for R1 were started due a surgical wound, and not for the sacral pressure injury. Furthermore, the HHCS staff reported that the RP, and facility staff were informed of the sacral pressure injury, which developed while R1 was in care.

Continues on LIC 9099C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-NP-20211202105836

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: JUST LIKE HOME II	FACILITY NUMBER: 197608927
	VISIT DATE: 09/15/2022

NARRATIVE

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The LPA conducted HHCS record review, which revealed that on 11/09/2021, HHCS staff reported that upon R1’s skin assessment, it was observed that R1 had developed ‘redness in the sacral area’. R1’s physician was informed, and per the physician’s orders, HHCS staff were to educate facility staff on the prevention of pressure injuries. HHCS record review revealed that HHCS staff instructed, and demonstrated to facility staff, the changing of R1’s position every 15 minutes (or not more than two hours), while on the bed, and sitting on the wheelchair to prevent pressure injuries. HHCS staff instructed facility staff to roll R1 to their sides to relieve pressure on the back, putting pillows in-between R1’s knees, and ankles to prevent pressure injuries when R1 was in bed. HHCS staff also instructed facility staff to assist R1 with sit-up exercises to help relieve R1’s pressure on the buttock area, while R1 was sitting on the wheelchair.

On 08/29/2022 at 10:32 a.m., staff interviews revealed that they were repositioning R1 every two hours, and as needed. Staff stated that they moved R1 from the bed to the wheelchair, and from the wheelchair to the sofa, and vice versa. Staff did not state whether they were assisting R1 with sit-up exercises. Staff stated that they ensured R1’s was kept dry by changing R1’s diaper every two hours or more often if needed.

On 11/017/2021, HHCS records review revealed that HHCS staff reported that upon R1’s skin assessment, it was observed that there was an open wound on the sacral area with a diameter of 2cm. x 3cm. The physician ordered wound care for R1. HHCS staff provided the wound care per the physician’s orders, and instructed facility staff to observe the wound, and provide wound care regimen daily.

Continues on LIC 9099C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-NP-20211202105836

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: JUST LIKE HOME II	FACILITY NUMBER: 197608927
	VISIT DATE: 09/15/2022

NARRATIVE

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The LPA was concerned what type of “wound care” the staff was providing, as only appropriately skilled professionals (Licensed Vocational Nurse [LVN] or higher) are allowed to provide wound care for pressure injuries. Staff interviews revealed that they kept the wound area clean, by irrigating the wound with the cleaning solution, applying ointments around the wound area and covering the wound with a dry dressing. The administrator’s interview revealed that they were aware of the change in condition and stated that staff was instructed to only change the dressing and apply moisture cream around the sacral wound. However, since only appropriately skilled professionals are allowed to care for pressure injuries, this issue will be addressed on a case management visit.

Based on the information gathered, interviews, and records review, the resident sustained pressure injuries while in care. Although facility staff received instructions from HHCS staff on how to prevent pressure wounds, R1 developed pressure injuries, specifically in the sacral area, which started as ‘skin redness’, and progressed to a stage four (4) sacral pressure injury, and a wound on the left heel, while R1 was in care at the facility. Therefore, the allegation that ‘Resident sustained pressure injuries while in care’ is deemed SUBSTANTIATED at this time

Facility did not seek timely medical treatment for changes in resident's health.
On the allegation of ‘Facility did not seek timely medical treatment for changes in resident's health’, it is alleged that the facility staff did not seek timely medical treatment for Resident #1 (R1) when it was observed that R1’s health condition had changed; consequently, R1 developed a stage four (4) sacral pressure injury. To investigate this allegation, the LPA conducted records review and staff interviews.

Continues on LIC 9099C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-NP-20211202105836

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: JUST LIKE HOME II	FACILITY NUMBER: 197608927
	VISIT DATE: 09/15/2022

NARRATIVE

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The Home Health Care Services (HHCS) record review revealed that the HHCS staff reported R1’s changes in condition on 11/09/2021 and 11/16/2021. On 11/09/2021, the HHCS staff reported that upon R1’s skin assessment, it was observed that R1 had developed ‘redness in the sacral area’. On 11/16/2021, HHCS staff reported that upon R1’s skin assessment, it was observed that there was an open wound on the sacral area with a diameter of 2cm. x 3cm. The HHCS staff provided wound care regimen per physician’s instructions. Facility staff were instructed to continue wound regimen daily. Staff interviews revealed that they kept the wound area clean by irrigating the wound with a cleaning solution, applying ointments around the wound area, and covering the wound with a dry dressing. As noted on the previous allegation, this will be addressed on a case management visit, as only appropriately skilled professionals may provide care to pressure injuries. The HHCS record review revealed that on 11/20/2021, a conversation with R1’s responsible party (RP) was held; the HHCS recommended for a wound specialist to see R1; however, the RP declined a wound specialist visit; and, any invasive wound treatment. As a result, the facility staff did not seek any further treatment for R1; though they should have elevated the HHCS concerns to the resident’s physician and sought a higher level of care for R1 versus retaining R1 in the facility with a prohibited health condition.

Based on the information gathered, and records review, the facility staff did not seek timely medical treatment for changes in resident's health. Although the HHCS staff informed the facility staff of the deterioration of the skin of the sacral area, the facility staff did not notify R1’s physician so that they further the resident in seeking timely medical treatment. As a result, the pressure injury progressed to a stage four (4) while in care. Therefore, the allegation that the Facility did not seek timely medical treatment for changes in resident's health is deemed SUBSTANTIATED at this time.
Continues on LIC 9099C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-NP-20211202105836

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: JUST LIKE HOME II	FACILITY NUMBER: 197608927
	VISIT DATE: 09/15/2022

NARRATIVE

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The following deficiencies are observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. An immediate $500 civil penalty is being assessed today.

Citations were issued. Exit interview conducted with the administrator, and signatures were obtained. A copy of the report, and Appeal Rights were issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 29-NP-20211202105836

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: JUST LIKE HOME II	FACILITY NUMBER: 197608927
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/30/2022 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained...: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: Schedule a training for all staff regarding prohibited health conditions. Verification of scheduled training with the trainer’s credentials will need to be submitted by 9/23/22, and completion of training must be submitted no later than 9/30/22.
	8 9 10 11 12 13 14	Based on the information obtained, record review and interviews, the licensee did not comply with the section cited above, as the Resident sustained pressure injuries while in care, and developed a stage four (4) sacral wound, and was retained in the facility with a prohibited health condition, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 09/30/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	87466-The licensee shall ensure that residents are regularly observed for changes in physical...When changes such as …a physical health condition are observed, the licensee shall ensure that such changes are... brought to the attention of the resident's physician and ... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Schedule a training regarding the observation of changes in resident health and conditions; and, who to contact when those changes are observed. Verification of scheduled training with the trainer’s credentials will need to be submitted by 9/23/22, and completion of training must be submitted no later than 9/30/22.
	8 9 10 11 12 13 14	Based on the investigation, staff failed to timely observe R1s change in physical health condition, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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