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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609340
Report Date: 05/17/2022
Date Signed: 05/17/2022 06:17:47 PM

Substantiated


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
01/30/2020 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200130140143
FACILITY NAME:JACKIE'S HIDEAWAY AFACILITY NUMBER:
197609340
ADMINISTRATOR:TAL, TALYFACILITY TYPE:
740
ADDRESS:5925 DONNA AVETELEPHONE:
(818) 345-6752
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 6DATE:
05/17/2022
UNANNOUNCEDTIME BEGAN:
05:20 PM
MET WITH:Taly TalTIME COMPLETED:
06:25 PM
ALLEGATION(S):
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Resident 1 (R1) sustained an unexplained fracture while in care
Licensee/Staff failed to seek timely medical attention
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan to deliver the findings regarding the allegations, ‘Resident sustained an unexplained fracture while in care of staff and, Facility staff failed to seek timely medical attention for resident.

On 03-20-2019, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s, Investigation Branch. The investigation was assigned to Investigator, Dennis Douglas.

On 3/22/2019 an initial 10-day visit was conducted at Jackie’s Hideaway B Facility # 197609341 by LPA N. Gillyard to initiate the investigation. On that day LPA Gillyard conducted tour of the facility reviewed records and obtained copies of pertinent records. During the course of the investigation information obtained revealed that the complaint was written in error for Jackie’s Hideaway B, therefore on 1/30/2020 a new complaint was generated for this facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
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-20200130140143
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: JACKIE'S HIDEAWAY A
FACILITY NUMBER: 197609340
VISIT DATE: 05/17/2022
NARRATIVE
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Medical records were requested by the office of Investigations. The records were received and reviewed on 04-22-2019 by Investigator Douglas. Additionally, on 4/10/2019 and 7/1/2019 Investigator Douglas conducted interviews with, administrator, staff and other relevant parties.

The investigation revealed that on 03-17-2019 Resident #1(R1) was showing signs of pain in the hip and or leg. The resident was unable to express pain verbally. Facility staff members attempted to assess the resident to find out what was hurting by the resident’s reaction when the resident was moved. The staff logs indicate that R1 complained about pain on the left hip and leg on 03-18-2019. In-addition the resident had a temperature of 102 degrees and appeared to show signs of abdominal pain. At which time the family was notified. Staff interviews revealed resident had previous falls approximately 3 weeks prior, staff denied R1 sustained a recent fall and denied knowing the cause for the recently developed pain.

On 03-19-2019 the Administrator had spoken to a Kaiser Nurse Practitioner who recommended that R1 be sent to the hospital, to which the facility Administrator initially declined. The Administrator acknowledged it was ultimately the resident’s family/POA (Power of Attorney) to have R1 transported to the Kaiser hospital as a precaution.

Additionally, on 3/17/2022 LPA Avetisyan requested Pre hospital Care Report Summary from the Los Angeles Fire Department Emergency Medical Services. Records were received and reviewed on 3/30/2022. According to the paramedic documentation they responded to a call for a 71 year old with complaint of left hip pain from ground level mechanical fall.

Reviewed medical records revealed upon hospitalization X-rays of R1’s left hip were taken. The x-rays indicated that R1 sustained mildly displaced/impacted fracture of the femoral neck. Staff interviews confirmed that R1 was complaining of pain for about 3 days and administrator declined to obtain medical care. Medical care was obtained at the request of R1’s POA.

Therefore, the allegations of Resident 1 (R1) sustained an unexplained fracture while in care and Licensee/Staff failed to seek timely medical attention are substantiated.


Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited.
Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20200130140143
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: JACKIE'S HIDEAWAY A
FACILITY NUMBER: 197609340
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2022
Section Cited
CCR
87464
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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidence by:
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Licensee/Administrator will schedule vendorized training related to the cited section

Verification of scheduled training with the trainers credentials will need to e submitted by 5/19/2022 and completed by 6/2/2022.
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Based on information obtained during the course of the IB investigation the licensee did not comply with the section cited above, as R1 suffered a broken bone unknown to staff, which posed an immediate health, safety or personal rights risk to R1.
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Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87464
Type A
05/19/2022
Section Cited
CCR
87465(a)(1)(2)
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(1) The licensee shall arrange, or assist in arranging, for medical … care appropriate to the conditions and needs of residents. (2) The licensee shall provide assistance in meeting necessary medical … needs. This includes transportation which may be limited to the nearest available medical … facility which will meet the resident's need…
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Licensee/Administrator will schedule vendorized training related to the cited section

Verification of scheduled training with the trainers credentials will need to e submitted by 5/19/2022 and completed by 6/2/2022.

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This requirement was not met as evidenced by: Based on information obtained during the course of the IB investigation the licensee did not comply with the section cited by not obtaining medical care when staff observed R1 in pain and recommended by nurse practitioner which posed an immediate health, safety or personal rights risk to R1.
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Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87465

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3