197608982-5-8-2023-29-AS-DPEA-CS6VHE-20230525162657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608982
Report Date: 05/08/2023
Date Signed: 05/08/2023 03:45:57 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210309110238

FACILITY NAME:	WALNUT GARDEN VALLEY VILLAGE		FACILITY NUMBER:	197608982
ADMINISTRATOR:	BUDNERO, MAIA DR		FACILITY TYPE:	740
ADDRESS:	12823 COLLINS STREET		TELEPHONE:	(818) 358-2033
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	05/08/2023
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Izhak illouz		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained bed sore while in care.

INVESTIGATION FINDINGS:

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**This is the new amended report that includes additional information, which supersedes the report issued on 05/11/2021 **

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the allegation listed above. LPA met with Izhak Illouz, the facility administrator.
During the investigation, LPA conducted a physical plant tour virtually on 3/10/2021 as well as conducted interviews with facility staff, resident and other relevant parties. Additionally, LPA also gathered and reviewed facility documentation pertinent to the allegation. On 04/19/2023, LPA obtained and reviewed Kaiser Home Health records pertaining to R1’s Care.

It was alleged that Resident 1 (R1) sustained a bed sore while in care due to lack of care and supervision. Information gathered through interviews and records review revealed that R1 was admitted to the facility on 12/30/2020.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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-AS-20210309110238

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: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
	VISIT DATE: 05/08/2023

NARRATIVE

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Continued from 9099

Prior to admission, R1 had been receiving services from Kaiser Home Health since 2019 for wounds located on the buttocks and lower extremities. Home Health records reviewed indicated that on 12/18/2020, R1 had a wound located on R1’s right lower extremity, which had completely healed. On 01/22/2021, R1 was observed by home health with an open wound to lower left leg that measured less than 1 cm x 1 cm and was to be treated by cleansing and changing dressings daily. Interviews conducted with home health agency nurse and R1’s Responsible Party (RP) did not indicate that the facility neglected R1, nor did they express any potential or immediate concerns regarding the care of R1. R1’s family further stated that R1 was regularly monitored by home health. Moreover, interviews with Facility staff further revealed, they would encourage and assist R1 with rotating, moving around and exercises to alleviate any pressure to lower left leg. Interviews and records review confirmed R1’s wounds were regularly observed and treated by home health and home health did not stage R1’s wound above a stage two. Based on information gathered over the course of the investigation, the department does not have sufficient evidence to determine that R1 sustained bed sores while in care due to facility lack of care and supervision. Therefore, the allegation that due to lack of care and supervision, the Resident sustained bed sore while in care has been deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.

Signatures can be found on hard copy.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC9099 (FAS) - (06/04)

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