197609495-1-25-2023-31-AS-RRAZ-CPWSMX-20230314140039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609495
Report Date: 01/25/2023
Date Signed: 01/25/2023 12:43:01 PM

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
01/20/2023 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20230120121848

FACILITY NAME:	WOODLAKE LOVING CARE LLC		FACILITY NUMBER:	197609495
ADMINISTRATOR:	ARDAKANI, SHAKILA		FACILITY TYPE:	740
ADDRESS:	8016 WOODLAKE AVE		TELEPHONE:	(818) 217-6778
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91304
CAPACITY:	6	CENSUS: 6	DATE:	01/25/2023
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Shakila Ardanni		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to neglect resident had a fall in the facility resulting in injuries.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. LPA met with the administrator, Shakila Ardakani and advised her of the complaint. It was reported that Resident 1 (R1), suffered a fall and sustained a bad skin tear. R1 was taken to the hospital four (4) days later for the skin tear, but was also assessed to have bruising and a dislocated shoulder. R1 was treated while at the emergency room (ER), but was also admitted for further treatment. Today's investigation consisted of interviews with administrator and staff, that were held between 9:15am to 10:45am, record reviews, which were conducted between 10:45am to 11:30am, and a physical plant inspection.

According to the administrator and staff, R1 never had a fall while in care. Interviews with both the administrator and staff, reveal that R1 has a history of skin breakdown. The administrator stated that on 01/16/23, R1's skin condition was progressing and getting bad. Paramedics were called on that day, and R1 was taken to the hospital and admitted for treatment. Review of facility Incident Report, which was

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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 2

Control Number 31-AS-20230120121848

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: WOODLAKE LOVING CARE LLC	FACILITY NUMBER: 197609495
	VISIT DATE: 01/25/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

emailed to the licensing agency originally on 01/23/23 confirms that resident was taken to the hospital, via paramedics, for wound care and admitted for treatment on 01/16/23. Further review of R1's records confirm that R1 is assessed to have squamous cell carcinoma, which is a common form of skin cancer.

In addition to interviews with facility staff and record review, LPA interviewed R1's family, who confirms that R1 has skin cancer. R1's family stated they were aware that R1 was taken to the hospital for treatment on 01/16/23 because their skin condition was getting worse. R1's family stated they were also aware of the shoulder injury, but states that it could not have happened at the facility. It might have happened during R1's stay at the hospital or while en route to the hospital. R1's family visits the facility often, and had no concerns regarding the care and supervision from facility staff, stating they are satisfied with services provided to R1. Family member stated there is no reason to suspect neglect.

Based on the information obtained, there was insufficient evidence to corroborate the allegation of neglect, resulting to R1's injury. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2