197609342-10-27-2023-31-AS-NGID-CXM32T-20231115165225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609342
Report Date: 10/27/2023
Date Signed: 10/27/2023 10:59:25 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230616145625

FACILITY NAME:	LOS FELIZ GARDENS		FACILITY NUMBER:	197609342
ADMINISTRATOR:	SHAPIRO, NONNA		FACILITY TYPE:	740
ADDRESS:	205 E LOS FELIZ ROAD		TELEPHONE:	(818) 241-2273
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 104	DATE:	10/27/2023
		UNANNOUNCED	TIME BEGAN:	10:00 PM
MET WITH:	Theresa Trinidad, Assistant Administrator		TIME COMPLETED:	11:20 PM

ALLEGATION(S):

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Resident sustained multiple unexplained injuries while in care

INVESTIGATION FINDINGS:

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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analysts (LPAs) Angela Panushkina and Michael Cava to issue the findings of the above listed allegation. Upon arrival, LPAs were greeted by Staff, Maria Chengcuengca, who contacted the Administrator. LPAs met with the Assistant Administrator and explained the reason for the visit.

On 06/16/23, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation, “Resident sustained multiple unexplained injuries while in care.” The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to investigator, Christine Ferris.

On 06/19/23, an initial visit was conducted by LPA Panushkina. On that day LPA conducted tour of the facility, interviewed with facility staff and obtained copies of pertinent information related to the allegation.
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: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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-20230616145625

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: LOS FELIZ GARDENS	FACILITY NUMBER: 197609342
	VISIT DATE: 10/27/2023

NARRATIVE

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This complaint investigation was conducted by Christine Ferris, Investigator from Community Care Licensing Division’s Investigations Branch (IB). The investigation consisted of interviews with R1, facility Assistant Administrator (AA), Licensed Vocational Nurse (LVN), Glendale Police Department Detective, Facility Resident, R1's records review - included but not limited to Admission Agreement (dated: 09/30/18), Physician’s Report (dated: 11/15/22), Appraisal Needs and Services Plan (dated: 10/15/18, 10/04/19, 05/03/21 and 04/27/23), Progress Notes (dated: 05/24/23 and 06/16/23), Preplacement Appraisal Information and Resident Appraisal (dated: 04/19/19) and other relevant documentation. On 06/27/23, Investigator Ferris subpoenaed Glendale Police Department Report. On 08/04/23, Investigator Ferris followed up on a status of the inquiry. On 08/14/23, Investigator obtained and reviewed a copy of the report. In addition, Investigator subpoenaed R1’s Medical Records on 06/21/23 and reviewed on 07/17/23.

Allegation: "Resident sustained an unexplained injury in care."

The investigation findings revealed that R1 had been living at this facility since 2009, while it was licensed under “Emerald City”. At that time, R1 was independent and able to ambulate without an assistance. In 2017 change of ownership took place and the facility became “Los Feliz Gardens". During that year R1’s physical and mental health condition started to deteriorate. R1 became wheelchair bound, dependent and diagnosed with Alzheimer’s. On 06/16/23, R1 sustained multiple unexplained injuries. When Fire Department/
Paramedics first arrived, no one could explain what had happened. Due to lack of information and injuries observed, Fire Department Captain contacted the police for a possible assault. Investigator’s interview with LVN revealed that he/she had been employed by a Home Health Agency and treated patients at Los Feliz Gardens for three (3) years. On 06/16/23, LVN was assigned to see another resident for treatment, at Los Feliz Gardens. Around 7:00am, LVN passed by R1’s room and observed R1 sitting on a wheelchair awaiting breakfast to be delivered. LVN went to see a wound patient near R1’s room and upon completion, about 7:30-7:45am, LVN passed by R1’s room and saw R1 "face down" on the floor near his/her dresser and R1’s wheelchair was on the side. LVN entered to assist R1. After R1 was placed on a wheelchair, LVN phoned 9-1-1, waited in the room until paramedics arrived and once paramedics arrived, LVN left the facility. On 06/19/23, during the initial visit, LPA Panushkina obtained a copy of “Care Coordination Notes” (dated on 06/16/23) confirming LVN’s statement. Moreover, Interview with Glendale Police Department, Detective, revealed that there has been no evidence to suggest that R1 was assaulted as initially assumed.

Continue on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230616145625

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: LOS FELIZ GARDENS	FACILITY NUMBER: 197609342
	VISIT DATE: 10/27/2023

NARRATIVE

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Detective informed the Investigator that R1’s injuries were more than likely a result of a fall. Additionally, Investigator’s interviews with three (3) residents revealed that the facility staff take very good care of R1 and attend his/her needs. All three (3) residents also informed the Investigator that the facility staff are attentive to their needs. Lastly, Hospital Discharge Diagnoses indicated R1 had an open fracture of metacarpal bone. During the initial visit conducted on 06/19/23, LPA Panushkina reviewed Progress Notes from 05/24/23 and 06/16/23 from R1’s Physician indicating that R1 is at high risk for pathological fracture due to severe osteoporosis. Based on interviews and document reviews, the investigation did not provide sufficient evidence to substantiate staff failed to provide proper supervision to R1 resulting in sustaining multiple injuries and fractures. Therefore, this allegation is deemed Unsubstantiated, at this time.

No deficiency cited during today's visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC9099 (FAS) - (06/04)

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