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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609306
Report Date: 01/23/2024
Date Signed: 01/23/2024 11:35:32 AM

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
01/08/2024 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240108173850
FACILITY NAME:ELAINE'S PLACEFACILITY NUMBER:
197609306
ADMINISTRATOR:BOTE, ELAINE PFACILITY TYPE:
740
ADDRESS:22745 DOLOROSA STREETTELEPHONE:
(818) 340-7769
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Elaine Bote, Licensee/AdministratorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Resident sustained severe pressure injury due to staff neglect
Facility staff did not meet resident's incontinence needs
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted a subsequent complaint investigation for the allegations listed above. LPAs arrived at the facility at 10:54AM and initially met with facility staff Norma Gregorio. Licensee/Administrator was contacted via telephone and arrived at 11:15AM. Entrance interview conducted.

During today's visit, LPAs toured the facility with Licensee/Administrator at 11:24AM. No immediate health and safety concerns were identified during today's visit. During an initial visit conducted on 01/10/2024, LPA Dulek interviewed staff at 10:28AM and toured the facility with staff at 10:43AM. LPA also reviewed and obtained copies of documents pertinent to the investigation, interviewed residents at 11:05AM and 11:55AM, and interviewed Administrator at 11:32AM. Throughout the course of the investigation, LPA reviewed all pertinent documents. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
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 2
Control Number 29-AS-20240108173850
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: ELAINE'S PLACE
FACILITY NUMBER: 197609306
VISIT DATE: 01/23/2024
NARRATIVE
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Allegation: Resident sustained severe pressure injury due to staff neglect:
The complaint alleges that Resident #1 (R1) sustained a severe pressure injury while residing at the facility due to staff neglecting R1’s needs. Interview revealed that R1 was admitted to the facility on 12/23/2023, following a brief stay at a Skilled Nursing Facility. Record review revealed that R1 had a sacral pressure injury prior to moving into the facility. R1’s physician’s report dated 12/22/2023 is marked “yes” under history of skin condition or breakdown, with the comment “sacral unstageable wound.” Physician’s report also indicates that R1 is receiving hospice care upon discharge from the skilled nursing facility. R1’s Appraisal Needs and Service Plan also indicates R1 is “currently receiving care through hospice agency” and indicates that R1 has a “unstageable pressure ulcer on sacrum and redness to right hip and buttocks area.” LPA reviewed R1’s hospice documents, which indicate R1 was receiving wound care three times per week while at the facility. Additional documentation reviewed indicates facility staff attempted to reposition R1 every two (2) hours even throughout the night. However, sometimes R1 refused and staff documented the refusal. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “resident sustained severe pressure injury due to staff neglect” is deemed UNSUBSTANTIATED at this time.

Allegation: Facility staff did not meet resident’s incontinence needs:
The complaint alleges that R1 was left lying in urine for 12-14 hours all night. Physician’s report indicates R1 had a “right side nephrostomy tube attached to drainage bag” to output R1’s urine, due to urinary retention. As R1 was admitted to hospice, effective 12/22/2023, prior to moving into the facility, interview revealed that hospice nurses were responsible for the care of R1’s nephrostomy tube/bag. Additionally, a staff interview revealed that prior to the complaint, R1 had multiple loose bowel movements, requiring additional incontinence care. Documentation reviewed revealed that R1 was changed additional times, due to the loose bowel movements. Staff interviewed indicated incontinent residents are checked every two hours throughout the day, as well as upon the residents’ request. LPA observed that each resident has a bell in their room to ring for additional assistance. Resident interviews revealed that their incontinence needs are regularly met and residents can call for additional assistance any time of the day or night. Staff conduct rounds during the overnight shift and rest in a common area where they can quickly respond to residents’ calls for assistance. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “facility staff did not meet resident’s incontinence needs” is deemed UNSUBSTANTIATED at this time.
No citations issued. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
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