197609362-10-8-2021-28-AS-EMAZ-C8DNUD-20211102104612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609362
Report Date: 10/08/2021
Date Signed: 10/08/2021 07:43:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2019 and conducted by Evaluator Don Senaha

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20190312103547

FACILITY NAME:	HEIGHTS AT BURBANK, THE		FACILITY NUMBER:	197609362
ADMINISTRATOR:	DAWN SMITH		FACILITY TYPE:	740
ADDRESS:	2721 WILLOW STREET		TELEPHONE:	(818) 954-9500
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	130	CENSUS: 80	DATE:	10/08/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Dawn Smith		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff left resident on toilet seat for extended amount of time resulting in bruising.

INVESTIGATION FINDINGS:

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On 03/20/2019, Licensing Program Analyst (LPA) Nicol Wesley initiated a complaint investigation for the allegation listed above. LPA met with Executive Director Dawn Smith to discuss the purpose for today’s visit.

On 09/29/21, Licensing Program Analyst (LPA) Don Senaha conducted a subsequent complaint investigation which consisted of gathering documentation. The investigation took place via the telephone and consisted of requesting the service documents.

On 10/08/2021, LPA Don Senaha and LPA Gail Johnson conducted a subsequent complaint investigation. Investigation consisted of a plant inspection, interviews client (R1-R12) and staff (S1-S2). LPA delivered findings.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

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-20190312103547

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: HEIGHTS AT BURBANK, THE	FACILITY NUMBER: 197609362
	VISIT DATE: 10/08/2021

NARRATIVE

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Allegation: Staff left resident on toilet seat for extended amount of time resulting in bruising.

The Investigation Branch’s Department conducted interviews with staff from this facility, staff from various associated hospitals, medical records/reports were reviewed and found there is evidence to corroborate the allegation “staff left resident on toilet seat for extended amount of time resulting in bruising”. On 03/10/2019, medical records upon admission to Providence St. Joseph’s Medical Center revealed “reddened area on buttocks, appears as if patient was sitting on toilet for extended period of time”. Medical records upon transfer to Kaiser Permanente Panorama City revealed “DTPI (Differentiating Deep Tissue Pressure Injury) to buttocks/sacrum, posterior thighs” and “seat burn along buttocks”.

Investigation Branch Department interview with staff (S1) on 06-05-2019 at 1325 hours, “staff (S1) said, at 0845 hours, (S1) went to resident (R1) room and (R1) was awake, sitting on the toilet and leaning on his right side”. Investigation Branch Department interview with staff (S2) on 06-28-2019 at 1000 hours, staff (S2) stated (S2) normally checked on resident (R1) when he was in bed, at 2230 or 2300 hours. There was no issues reported with resident (R1), on 03-09-2019, thus it did not appear staff (S2) checked on resident (R1) again, after 2230 or 2300 hours. Staff (S2) did not check on resident (R1) often because some of the residents, including (R1), did not like to be woken up by room checks.

Based on LPA’s interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20190312103547

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: HEIGHTS AT BURBANK, THE	FACILITY NUMBER: 197609362
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/08/2021 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Right of Residents in all Facilities (a) Residents in all residential care facilities… (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of punitive nature… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agreed to review California Code of Regulations Title 22 Section, Division 6, Chapter 8, Article 8. Personal Right of Residents in all Facilities. The Licensee provided in-service training with all staff regarding regulation 87468.1(a)(3) and develop a plan for medical
	8 9 10 11 12 13 14	Based on investigation report, record reviews and interviews, the licensee reported the resident was found on the toilet for an extended period of time and shaking noted to have marks on buttocks, which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	reassessment to ensure resident changes in condition are addressed according and included in the needs/services plan. The Licensee provided the in-service training documents immediately.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC9099 (FAS) - (06/04)

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