197609495-2-27-2024-31-AS-NMAN-D752JX-20240712172705

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609495
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:32:49 PM

Substantiated

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
03/23/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230323112447

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:	02/27/2024
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Belkees Bassam		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Resident sustained multiple severe pressure injuries due to staff neglect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 10:35 am to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was contacted and arrived later.

The initial visit was conducted by LPA Tihesha Smith on 03/24/2023, at which time LPA Smith conducted a physical plant tour at around 11:07 am and conducted an interviews with staff and requested documents relevant to the investigation at 11:18 am.

Resident sustained multiple severe pressure injuries due to staff neglect
Staff interviews conducted on 03/24/2023 at 11:18 am, revealed that upon admission to the facility, Resident #1 (R1) required help with all ADLs (Activity of Daily Living). A review of skilled nursing records and Physicians’ report skilled nursing records revealed that R1 was admitted to the facility with a pressure ulcer of sacral region stage 2. Wound progress notes revealed the following wound progression:

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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-20230323112447

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: 02/27/2024

NARRATIVE

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(Cont from 9099)

Wound #2 Sacral is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed.

Wound #3 Left, Lateral Lower Leg is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed with presence of slough.

Wound #5 Right Buttock is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed.

Wound #7 Left Back is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed.

Wound #8 Right Hip is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed

Wound #9 Right Upper Back is a chronic Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed.

Wound #10 Left Back lower is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed.

Interviews with administrator revealed that although they had wound care nurse, they did receive information that R1’s wounds were not healing. Overall, the investigation revealed that although facility staff including the Administrator had knowledge that R1’s pressure injuries were not healing, they failed to take appropriate measures to ensure that there is no immediate threat to the health and safety of the resident.

Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time.

Exit interview conducted. Appeal rights given. Copy of report given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230323112447

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/27/2024 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall submit a written plan describing how the facility shall prevent injuries to residents in care as a result of this deficiencies. Licensee shall submit to CCL no later than 03/1/24
	8 9 10 11 12 13 14	Based on record reviews & interviews, R1 wounds were not healing, and developed unstageable wounds while in care which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 02/27/2024 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health This requirement was not met as evidenced by:	1 2 3 4 5 6 7	he Administrator agreed to do the following: Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening and to ensure compliance to the cited regulation Licensee shall submit to CCL no later than 03/1/24
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited, as staff did not seek medical attention for R1 in a timely manner, which posed an immediate health and safety risk to R1.	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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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