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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608939
Report Date: 10/19/2022
Date Signed: 10/19/2022 05:15:28 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
04/06/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220406083922
FACILITY NAME:AAA JERUSALEM STARFACILITY NUMBER:
197608939
ADMINISTRATOR:VIACHESLAV SHCHERBAFACILITY TYPE:
740
ADDRESS:5945 CAPISTRANO AVENUETELEPHONE:
(818) 888-1706
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 6DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Viacheslav "Slava" ShcherbaTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Staff leave resident unattended in wet clothing for extended periods of time
Staff failed to treat resident with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced subsequent complaint inspection. The LPA met with Administrator Viacheslav 'Slava' Scherba and explained the reason for the visit.

During today’s visit, the LPA conducted a brief physical plant tour at 10:20 a.m., interviewed residents at 10:30 a.m., 11:10 a.m. and 11:25 a.m., interviewed staff at 10:50 a.m. and 11:38 a.m.

Regarding the allegation: Staff leave resident unattended in wet clothing for extended periods of time
It was alleged that R1 is not being changed by facility staff in a timely manner leaving R1 in soaking wet diapers for extended periods of time. Medical records obtained revealed that R1 has a history of incontinence and an overactive bladder.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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 4
Control Number 29-AS-20220406083922
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: AAA JERUSALEM STAR
FACILITY NUMBER: 197608939
VISIT DATE: 10/19/2022
NARRATIVE
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Based on interviews R1 requested to be changed frequently and per R1’s Appraisal/Needs and Services Plan dated 2/28/2021 it was revealed the that facility was aware that R1 needs consisted of bowel impairment which required continuous bed care. Plan established by the facility indicated that direct care staff for R1 would ensure that R1 received all the necessary attention and address any physical/health issues observed. Based on video surveillance received dated 4/5/2021 by R1's responsible party (RP) the LPA observed Staff #1 (S1) explaining to R1 that R1 was just changed and did not need to be changed again as they were only a little wet. Interviews also revealed that the resident needs a Hoyer lift and although R1 only requires a one person assist, interview with licensee confirmed that Staff #2 (S2) required a second staff for assistance as R1 was too heavy for S2 to lift or reposition alone. Interview with S2 revealed that rather than asking staff to help S2 with repositioning R1 they would ask R1 to help with repositioning themselves in order to avoid requesting a second staff for assistance. Interviews further revealed that on 4/5/2022 R1 asked to be changed after S1 had left for the day and S2 communicated to R1 that they had too wait until S1 would return to the facility to be changed. Based on interviews and record review the allegation is deemed Substantiated at this time.

Regarding the allegation: Staff failed to treat resident with dignity and respect

On 4/13/22, the LPA interviewed owner/licensee at which time the LPA observed the licensee become agitated when discussing the above allegation. Video surveillance confirmed that the licensee had several interactions with R1 that verified the licensee’s actions toward R1. Video surveillance showed the licensee raising their voice at R1, pacing back and forth in their room, throwing their arms up in the air from frustration toward the residents requests, speaking to the resident in a harsh manner and making R1 feel bad for asking for, so many requests. When discussing these allegations, the licensee confirmed these actions. Interview with R1 confirmed that staff are frustrated with helping them and staff interviews confirmed that R1 made consistent requests. The allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220406083922
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: AAA JERUSALEM STAR
FACILITY NUMBER: 197608939
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Administrator agrees to the following:
1. Conduct an in-service traininig, regarding incontinence care and resident personal rights. Provide proof to CCL no later than 10/25/22.
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Based on interviews, the licensee did not comply with the section cited above, as R1 was left soiled for an extended period of time which poses an immediate health and safety risk to residents in care.
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Type A
10/25/2022
Section Cited
CCR
87486.1(a)(1)
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87468.1(a)(1) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1. Provide staff training on personal rights, and how to treat residents with dignity and respect. 2.Submit proof of staff training to CCL by 10/25/22.
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Based on interviews conducted, the licensee failed to ensure that R1 was accorded with dignity in their personal relationships with staff which posed an immediate safety and personal rights 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4