197609118-7-15-2024-31-AS-TAGD-D78TZE-20240716151013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609118
Report Date: 07/12/2024
Date Signed: 07/15/2024 08:01:07 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
10/23/2023 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20231023100637

FACILITY NAME:	CAPLAND SENIOR LIVING		FACILITY NUMBER:	197609118
ADMINISTRATOR:	MANABAT II, EMMANUEL A		FACILITY TYPE:	740
ADDRESS:	39927 CAPLAND DRIVE		TELEPHONE:	(661) 480-0082
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 3	DATE:	07/12/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Emmanuel Manabat II		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care
Staff are providing poor food service
Staff are not meeting resident's diapering needs
Staff are billing residents for services not provided
Staff leave residents in bed for an extended period of time

INVESTIGATION FINDINGS:

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On 7/12/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by Caregiver. The Administrator arrived at 9:30 am. LPA explained the purpose of this visit was to conduct interviews and present findings. LPA Spaeth interviewed the three (3) of the four (4) caregivers via phone call at 8:00 am until 8:30 am. LPA Spaeth interviwed the Administrator at 12:00 pm until 12:30 pm.

The investigation consisted of the following: On 10/27/2023 LPA Spaeth initiated a complaint investigation. LPA reviewed resident files and interviewed a resident.

LPA toured the facility with the caregiver at 9:30 am until 9:45 am. At 9:30 am, LPA observed a seven-day supply of perishable food and a two-day supply of non-perishable food. LPA did not observe any health or safety issues.
Continued - 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

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 3

Control Number 31-AS-20231023100637

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAPLAND SENIOR LIVING	FACILITY NUMBER: 197609118
	VISIT DATE: 07/12/2024

NARRATIVE

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LPA Spaeth reviewed residents’ files 9:45 am until 10:15 am. LPA received copies of the residents' documents, the resident roster, the staff work schedule and a copy of the facility menu.

Regarding the allegation: Resident sustained an unexplained injury while in care. It’s being alleged that a resident’s leg is bruised and bleeding and the Administrator does not properly document regarding what happened to the resident’s leg. Three (3) of the four (4) staff members (S1, S2, S3) stated there are no residents who currently have wounds and stated there has been no injuries. The Administrator stated a previous resident had a skin tear which was treated by a Kaiser wound nurse during the month of October, 2023. LPA received the facility sign in sheet and observed the nurse had provided wound care to the previous resident. The Administrator stated they had been advised to change the bandages each day and stated the wound was not an injury. Therefore the allegation is unsubstantiated.

Regarding the allegation, Staff are providing poor food service. It’s being alleged the meals are lacking, are small, food is not nutritious, and there is not an adequate supply of food in the facility. During LPA's facility tour, LPA observed an adequate supply of food which included dairy, fresh fruits and vegetables, and frozen meat. LPA interviewed one resident (R1) out of the three residents (R2 - R3). R1 stated they are always provided enough food to eat and they like the food that is prepared. R2 and R3 were unable to answer LPA's questions. The menu was posted in the kitchen and LPA observed nutritious food is provided at each meal. S1 - S3 stated there is always an adequate supply of nutritious food. The Administrator stated they purchase food two times a week. Therefore the allegation is unsubstantiated.

Regarding the allegation, Staff are not meeting resident’s diapering needs. It’s being alleged residents are left in bed for an extended period of time, and residents diapers are not regularly changed. R1 stated their diaper is changed every two hours and even during the night. R2 and R3 were unable to answer LPA's questions. S1 - S3 unanimously stated they change the resident's diapers every two hours. Therefore the allegation is unsubstantiated.

Regarding the allegation, Staff are billing residents for services not provided. It’s being alleged that a resident left the facility due to the facility staff not providing care needed but still charged the resident for care

Continued 9099-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20231023100637

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAPLAND SENIOR LIVING	FACILITY NUMBER: 197609118
	VISIT DATE: 07/12/2024

NARRATIVE

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and supervision. LPA spoke to a resident's family member at 12:00 noon who stated the facility has never charged for services that were not provided. The family member stated the staff provide the care needed and the facility has never overbilled the resident. The Administrator stated family members have not complained about the services provided and the facility has not overcharged for services rendered. Therefore the allegation is unsubstantiated.

Regarding the allegation, staff leave residents in bed for an extended period of time. It’s being alleged the staff are forcing the residents to go to bed at 7pm and the staff leave the resident in bed until 9:00 am. S1 - S3 stated they never force residents to go to bed at 7:00 pm and never leave them in their bed until 9:00 am. R1 stated they make the decision when they go to bed. R2 and R3 were unable to answer LPA's questions. The Administrator denied the allegation. Therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of the report was given.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

LIC9099 (FAS) - (06/04)

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