197609342-12-8-2021-28-AS-MVAO-CCSTAA-20220323143314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609342
Report Date: 12/08/2021
Date Signed: 12/08/2021 02:28:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2021 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210210163715

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: 127	DATE:	12/08/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Facility Adminitrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Personal Rights: Resident sustained multiple pressure injuries while in care
Personal Rights: Resident was found unresponsive at the facility due to a health condition.

INVESTIGATION FINDINGS:

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On 02/11/21: Licensing Program Analyst (LPA) Elizabeth Irra initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with
Nonna Shapiro (Facility Administrator). At approximately 3:15 P.M, LPA Irra spoke to the Facility Administrator via telephone. LPA requested relevant documentation. At approximately 3:45 P.M., LPA conducted a tele-visit tour of the building and grounds and did not observe any signs of neglect, abuse or other immediate health and safety threats.

During this investigation, the Department of Social Services Investigation Bureau Investigator conducted the following, interviewed the Facility Assistant Administrator and Facility LVN and obtained and reviewed R-1's hospital and skilled nursing facility medical records in regards to the above allegation(s). LPA interviewed S-1 and S-2 and reviewed R-1's file and obtained relevant documentation. Refer to LIC 9099C for the contination of this report.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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 28-AS-20210210163715

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LOS FELIZ GARDENS	FACILITY NUMBER: 197609342
	VISIT DATE: 12/08/2021

NARRATIVE

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Allegation/Personal Rights: Resident sustained multiple pressure injuries while in care.
The investigation revealed that on 02/08/21, R-1 was initially diagnosed in the Emergency Department with a stage III pressure injuries on R-1’s left and right side buttocks upon admission to the hospital. Per investigation, that same day of admission, a wound care nurse reassessed the wounds and diagnosed them as Stage II pressure injuries. Per facility staff interviews, on 01/27/2021, R-1 was sent to the hospital for generalized weakness with no pressure injuries noted. R-1 was discharged to a skilled nursing facility (on 01/30/21) up until R-1 was taken back to the hospital on 02/08/21. During the 02/08/21 hospital visit, R-1 was diagnosed with pressure injuries (as noted above). R-1 was treated and discharged back to the skilled nursing facility on 02/11/2021. R-1 did not return to this facility since 01/27/21 hospital admission. Medical records review from the skilled nursing facility did not identify any stage III pressure injuries upon R-1’s admission (01/30/21) to the skilled nursing facility. Interviews conducted and documentation reviewed do not corroborate this allegation.

Allegation/Personal Rights: Resident was found unresponsive at the facility due to a health condition.
On 02/08/21, R-1 (while residing at the skilled nursing facility), was taken to the hospital. Per facility staff interviews, on 01/27/2021, R-1 was sent to the hospital for generalized weakness. R-1 was discharged to a skilled nursing facility (on 01/30/21) up until R-1 was taken back to the hospital on 02/08/21. R-1 was treated and discharged back to the skilled nursing facility on 02/11/2021. R-1 did not return to this facility since 01/27/21 hospital admission. Interviews conducted and documentation reviewed do not corroborate this allegation.

Based on the information gathered, the allegations of “Resident sustained multiple pressure injuries while in care” and “Resident was found unresponsive at the facility due to a health condition” are unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. Therefore, the complaint allegation is being dismissed.

An exit interview was conducted and a copy of this report and Appeal Rights were provided to Facility Administrator.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

LIC9099 (FAS) - (06/04)

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