197609329-12-2-2021-29-AS-KBUY-C9PRE6-20211214115702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609329
Report Date: 12/02/2021
Date Signed: 12/02/2021 02:02:49 PM

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
06/26/2020 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20200626155635

FACILITY NAME:	SHALEV SENIOR LIVING 3		FACILITY NUMBER:	197609329
ADMINISTRATOR:	QUINTERO, ELEANOR		FACILITY TYPE:	740
ADDRESS:	5805 HILLVIEW PARK AVE		TELEPHONE:	(818) 780-4808
CITY:	VALLEY GLEN	STATE: CA	ZIP CODE:	91401
CAPACITY:	0	CENSUS: 0	DATE:	12/02/2021
		UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Mailed report to Licensee, Rudy Rezzadeh		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Facility staff left resident on the floor for an extended period of time.

INVESTIGATION FINDINGS:

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On 12/02/2021 at 1:17 pm, Licensing Program Analyst (LPA) Chavez mailed the final findings for the complaint investigation to the licensee, Rudy Rezzadeh.

On the allegation “Facility staff left resident on the floor for an extended period of time.,” the complainant’s concern was that staff were present when a Resident #1 (R1) fell on the cement outside and did not help the resident off the floor. The complainant was also concerned that the resident may have sustained injury from sitting in the sun for an extended period of time. To investigate this allegation, LPA interviewed the complainants, administrator, staff, and resident, and reviewed facility records.

Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

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-20200626155635

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: SHALEV SENIOR LIVING 3	FACILITY NUMBER: 197609329
	VISIT DATE: 12/02/2021

NARRATIVE

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On 4/14/21 at 1:08 pm, LPA Chavez interviewed Administrator Eleanor Quintero Jiminez by phone. Ms. Jiminez recounted the event the day R1 fell saying that “R1 fell from R1’s wheelchair, staff immediately called 911, and 911 arrived.” Staff records provided by the administrator indicate staff called 911 at 10:18 am. Administrator states that the facility’s protocol when a resident falls is to leave them in place and call 911. She explains the protocol assures staff are not injuring the resident. Administrator states there were four staff working at the facility the day R1 fell.

On 4/22/21 at 9:21 am, LPA Chavez interviewed Staff #1 (S1). S1 stated that S1 was inside the facility when R1 fell outside in the patio. S1 stated that R1 stood up from the wheelchair and fell. S1 states that “staff are trained to call 911 when a resident falls even if nothing is wrong with the resident. Any resident who falls, 911 is called.” S1 relayed that “one of the administrators called 911 when R1 fell.” S1 explains that Staff #2 (S2) was outside in the backyard where R1 fell. S1 expresses that “as soon as R1 fell, 911 was called immediately, and paramedics arrived within five minutes.” S1 says both caregivers stayed with R1 until paramedics arrived.

On 9/18/21 at 7:10 pm, LPA interviewed Witness #1 (W1). W1 informs that 911 received a call from the facility on 6/24/20 at 10:14 am and that paramedics and fire crew arrived at the facility at 10:19 am. W1 states that crews assisted R1 from the floor in the backyard into R1’s wheelchair. They assessed R1 and found no injuries, no complaints of pain, and vitals were stable.

On 4/16/21 at 3:46 pm, LPA reviewed resident records indicating R1 had been given x-rays the same day after the fall. X-rays were taken of R1’s right femur, hip, and shoulder and findings state that R1 sustained “no fractures, malalignment, nor dislocations.” LPA reviewed weather report archives for 6/24/20, which indicated a high temperature of 75 degrees Fahrenheit and a low temperature of 63 degrees Fahrenheit.

Based on the evidence obtained in this investigation, the findings do not support that R1 was left in the sun unassisted for an extended period of time and that R1 did not sustain injuries. As a result, regarding the allegation that, “Facility staff left resident on the floor for an extended period of time”, the finding is Unsubstantiated.

No deficiencies cited. Report mailed to licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC9099 (FAS) - (06/04)

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