197609349-10-20-2020-29-AS-JAPL-BUSPHA-20201027111936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609349
Report Date: 10/20/2020
Date Signed: 10/20/2020 02:14:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/09/2020 and conducted by Evaluator Aja Richardson

COMPLAINT CONTROL NUMBER: 29-AS-20201009141055

FACILITY NAME:	A BETTER LOVE BOARD AND CARE		FACILITY NUMBER:	197609349
ADMINISTRATOR:	MACANDILI, EDJESKA		FACILITY TYPE:	740
ADDRESS:	6108 SADRING AVE		TELEPHONE:	(747) 226-0439
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	10/20/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Edjeska Macandilli, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff failed to follow reporting requirements
Facility staff failed to provide resident adequate supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Aja RIchardson conducted a subsequent complaint visit for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Edjeska Macandilli.
Allegation # 1: There are concerns that Resident #1 (R1) who is unable to leave the facility unassisted, eloped from the facility and faciilty did not report incident to the required agencies (law enforcement, Long Term Care Ombudsmen, and Licensing). On 10/19/20, from 9 am to 11 am, LPA conducted interviews with the Administrator, facility staff, and R1's previous roommate at the facility. On 10/20/20 at 11 am, LPA interviewed the Administrator again as well as a third party agency. At 11:30 am LPA reviewed R1's records including two incident reports and R1's physician report. Based on interviews conducted, R1 had a tendency to leave the facility unassisted. At times, R1 would let the facility staff know and other times R1 would sneak out by turning off facility door alarms.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

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 29-AS-20201009141055

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: A BETTER LOVE BOARD AND CARE	FACILITY NUMBER: 197609349
	VISIT DATE: 10/20/2020

NARRATIVE

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Based on R1's physician report R1 is unable to leave facility unassisted. The Administrator stated that she did not submit reports for the previous incidents where R1 left facility unattended but did submit an incident report for this incident. However, licensing did not receive the incident report and the Administrator was unable to provide a fax confirmation. Based on interviews, resident was missing from facility from 09/29/20 to 09/30/20 before being picked up by paramedics in the middle of the street and taken to the hospital. Based on facility staff interviews, staff did not know where R1 was located and there were multiple previous instances of R1 leaving facility unassisted without being reported to licensing. In addition, based on facility administrator not notifying law enforcement, long term care ombudsman and unable to provide confirmation that this incident occurring on 9/29/20 was reported to licensing within 7 days this allegation is Substantiated.

Allegation #2: There are concerns that R1 left facility unassisted and facility staff did not provide adequate supervision. To investigate this allegation, on 10/19/20, from 9 am to 11 am, LPA conducted interviews with the Administrator, facility staff, and R1's previous roommate at the facility. On 10/20/20 at 11 am, LPA interviewed the Administrator again as well as a third party agency. At 11:30 am LPA reviewed R1's records including two incident reports and R1's physician report. According to interviews and record review, R1 left facility at 4 am on 9/29/20 and was found in the middle of the street several miles from the facility intoxicated and in poor condition. On 9/30/20, R1 was taken to the hospital and then transferred to a skilled nursing due to needing a higher level of care. According to interviews with the Administrator, staff, R1's roommate, and a third party agency, R1 repeatedly left facility unassisted and would at times alert the staff and on other occasions would leave without notifying staff. On 9/29/20, R1 left facility turned off the door alarm and is believed to have used public transportation to travel to Los Angeles. The review of R1's physician report revealed that R1 is unable to leave facility unassisted and therefore facility failed to provide proper supervision for R1. This allegation is Substantiated.

Exit Interview Conducted. Due to televisit; report emailed to Administrator and signed hard copy requested by LPA.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20201009141055

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: A BETTER LOVE BOARD AND CARE	FACILITY NUMBER: 197609349
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/20/2020 Section Cited CCR 87468(a)(2)	1 2 3 4 5 6 7	87468(a)(2) Personal Rights. (a) Each resident shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	1. Administrator agreed to submit proof of registration from an approved vendor indicating the vendors name, address, phone number and the schedule for training on Personal Rights and leaving facility unassisted to all staff including the Administrator at the facility. Please send registration of training by 10/21/2020 and then once completed.
	8 9 10 11 12 13 14	Based on interviews and record review administrator failed to ensure that R1 was accorded safe and healthful accommodations due to R1 leaving faciity unassisted and on 9/30/20 found intoxicated and in poor health,, which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 10/20/2020 Section Cited CCR 87411(a)(1)(D)	1 2 3 4 5 6 7	87411(a)(1)(D)Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	All staff including Administrator to take state approved vendored training on Reporting Requirements. Submit registration of training by 10/21/20. The training material and staff sign in sheet to CCL once completed.
	8 9 10 11 12 13 14	Based on interviews and file review the Administrator failed to report the elopement of R1 to CCL and other agencies within 7 days which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3