197609016-1-3-2023-31-AS-NGID-CN2RFZ-20230113115959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609016
Report Date: 01/03/2023
Date Signed: 01/03/2023 01:15:53 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
08/22/2022 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20220822164636

FACILITY NAME:	ARK CARE HOME LLC		FACILITY NUMBER:	197609016
ADMINISTRATOR:	MANDAC, ADELAIDA Q		FACILITY TYPE:	740
ADDRESS:	37616 RIBBON LANE		TELEPHONE:	(661) 526-4066
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93552
CAPACITY:	6	CENSUS: 0	DATE:	01/03/2023
		ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Richard Mandac, Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff caused injury to resident
Resident has sustained multiple falls while in care

INVESTIGATION FINDINGS:

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On December 6th 2022, the Regional Office (RO) received a written notification from the Administrator informing that the facility suffered a water damage on December 3rd, 2022 and will be temporarily closed until the repair has been completed and ready to resume buisness. RO was also informed that the facility had no residents since September 16th, 2022. For convenience, Licensing Program Analyst (LPA) Angela Panushkina will deliver the findings regarding the allegations, “Staff caused injury to resident, Resident has sustained multiple falls while in care” on 01/03/2023 at the Regional Office located on 21731 VENTURA BLVD., #250, WOODLAND HILLS, CA 91364. Adminitrator arrived at 1:00pm and LPA explained the reason for todays visit.

On 08/22/22, a complaint was received by the Woodland Hills South Adult and Senior Care Regional Office. On 08/23/22 the complaint was referred to and accepted by Community Care Licensing Division’s, Investigation Branch. The investigation was assigned to Investigator, Jose Santana.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

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 31-AS-20220822164636

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: ARK CARE HOME LLC	FACILITY NUMBER: 197609016
	VISIT DATE: 01/03/2023

NARRATIVE

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On 08/23/22 an initial 10-day visit was conducted by LPA S. Stamps to initiate the investigation. On that day LPA Stamps conducted tour of the facility reviewed records and obtained copies of pertinent records.

Medical records were requested by the office of Investigations on 09/08/2022. The records were reviewed by
Investigator Santana on 09/13/22. Additionally, on various days 08/29/2022, 08/30/2022, 08/31/2022, 09/13/22, 09/19/22, 09/29/22 and 10/11/22 Investigator Santana conducted interviews with, R1, Hospital Social Worker, R1’s family member, R1's former Power of Attorney, facility staff, facility Administrator and on 08/26/2022 conducted interview with the complainant.

Records reviewed and interviews conducted revealed the following:

R1 was admitted to this facility on 09/01/18 with a diagnoses of generalized muscle weakness and poor gait. Although R1 maintains that his/her arm bruising and leg skin tear were the result of physical abuse at the facility, R1 declined to provide specifics and mentioned only that she/he slipped on water that caregivers somehow placed on the floor. Based on interviews with caregivers and paramedics, R1’s left leg skin tear is believed to have resulted from a fall off the toilet onto the floor. Facility caregivers denied physical abuse and the Investigator was informed, during his interviews, that the alleged perpetrator, Staff #1 (S1), has not been present at the facility since 2020. Therefore, the allegation that Staff caused injury to resident is Unsubstantiated.

Investigator’s interviews with the Administrator, facility staff (S2) and R1’s primary Physician revealed that by March 2022, R1 was ambulating with a walker and was ordered physical therapy sessions, which R1 refused. The facility repeatedly instructed R1 to call for help when requiring assistance, R1 failed to do so and resulted in at least six falls between 7/20/2022 and 8/20/2022. The facility was compliant with providing tools and guidance R1 needed to safely ambulate; it complied with reporting requirements and seeking medical treatment following R1’s falls; and it took steps to minimize the recurrence of falls by arranging for adjustment of medications, replacing R1’s footwear, and installing grab bars in the bathroom. Therefore, the allegation Resident sustained multiple falls while in care is deemed Unsubstantiated at this time.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

LIC9099 (FAS) - (06/04)

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