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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609632
Report Date: 06/01/2022
Date Signed: 06/01/2022 10:16:34 AM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220218085027
FACILITY NAME:RESERVE AT THOUSAND OAKS, THEFACILITY NUMBER:
197609632
ADMINISTRATOR:SPENCER, ELIZABETHFACILITY TYPE:
740
ADDRESS:3575 N. MOORPARK ROADTELEPHONE:
(805) 492-2471
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:170CENSUS: 147DATE:
06/01/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth SpencerTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Due to neglect, resident's pressure injury progressed to a stage 3 pressure injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Executive Director Elizabeth Spencer and explained the reason for the visit.

On 02/18/2022, the Department received a complaint, alleging that due to neglect, Resident #1’s (R1) pressure injury progressed to a stage 3 pressure injury while in care. On 02/22/2022, the LPA conducted the initial visit and interviewed ten (10) staff from 10:00 a.m. - 3:10 p.m. and obtained pertinent documents. In addition, the LPA interviewed a medical professional whom provided care for Resident #1 (R1) on 02/24/2022 at 3:22 p.m. Lastly, the LPA requested medical records on 03/03/2022 and received the records on 03/25/2022.


CONT 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
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 6
Control Number 29-AS-20220218085027
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: RESERVE AT THOUSAND OAKS, THE
FACILITY NUMBER: 197609632
VISIT DATE: 06/01/2022
NARRATIVE
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The investigation revealed that Resident #1 (R1) was admitted to this facility on 11/12/2021. Interviews and records review revealed that R1 was discharged from a skilled nursing facility, in which R1 had recently had a stroke and was diagnosed with a stage two pressure injury. However, the pressure injury had healed. R1 was admitted to this facility with home health services for speech, occupational, and physical therapy.

Interviews revealed that on 1/12/2022, R1 was visited by home health and R1 was observed with a wound on the coccyx. The wound was diagnosed as a stage two pressure injury. As such, home health requested an order for an air mattress and on 1/13/2022, home health requested an order for staff to reposition R1 every two hours. Home health requested an additional wound evaluation, yet R1’s primary care physician noted that R1 needed to be seen by their provider to determine appropriate treatment. Thereafter, the frequency of home health visits increased to approximately three times a week due to the progression of the wound.

Prior to this, medical records confirmed that facility staff communicated to R1’s primary care physician that if R1’s wound was staged above a stage two, the facility would be unable to retain R1 in this facility. Thus, R1 had an appointment with their primary care physician on 1/19/2022. Interviews confirmed that staff were not immediately notified regarding the staging of R1’s pressure injury after the 1/19/2022 physician’s visit. In fact, medical records review confirmed that on 1/21/2022, facility staff sent a note to R1’s physician, requesting information regarding the staging of the wound. Thereafter, R1’s physician sent over documentation, confirming that the wound was evaluated as a ‘stage three-four pressure injury’. After receiving the documentation, the facility recognized that R1 needed a higher level of care, and R1 was sent to the emergency room on 1/21/2022. R1 was admitted to the hospital and was discharged to a skilled nursing facility on 1/22/2022 for wound care. R1 did not return to the facility.

Staff claimed to have regularly repositioned R1, yet it was communicated by the majority of staff that R1 was resistant to repositioning and would oftentimes ‘return’ to an original position after being repositioned. An interview with home health confirmed that home health had no concerns regarding the care that R1 received at the facility and believed there was insufficient evidence to claim that staff failed to reposition R1, as wounds can rapidly progress within hours.

CONT 9099-C
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220218085027
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: RESERVE AT THOUSAND OAKS, THE
FACILITY NUMBER: 197609632
VISIT DATE: 06/01/2022
NARRATIVE
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Records review and interviews further confirmed that R1’s wound was regularly observed and treated by home health, and home health did not stage R1’s wound above a stage two throughout the duration of R1 residing at this facility. Once the facility received documentation that the wound had progressed to a stage three pressure injury, the facility noted that R1 needed a higher level of care and R1 was sent to the emergency room.

Based on the information provided, there is insufficient evidence to support the claim that due to neglect, R1’s stage two pressure injury progressed to a stage three pressure injury while in care. R1’s pressure injury was regularly observed and assessed by an appropriately skilled professional while residing at this facility. The investigation did not reveal any suspicion of neglect or lack of care from home health or hospital staff. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
02/18/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220218085027

FACILITY NAME:RESERVE AT THOUSAND OAKS, THEFACILITY NUMBER:
197609632
ADMINISTRATOR:SPENCER, ELIZABETHFACILITY TYPE:
740
ADDRESS:3575 N. MOORPARK ROADTELEPHONE:
(805) 492-2471
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:170CENSUS: 147DATE:
06/01/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth SpencerTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff did not safeguard resident belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Executive Director Elizabeth Spencer and explained the reason for the visit.

On 02/18/2022, the Department received a complaint, alleging alleging that the facility failed to safeguard R1’s belongings as it pertained to an air mattress. On 02/22/2022, the LPA conducted the initial visit and interviewed ten (10) staff from 10:00 a.m. - 3:10 p.m. and obtained pertinent documents. In addition, the LPA interviewed a medical professional whom provided care for Resident #1 (R1) on 02/24/2022 at 3:22 p.m. Lastly, the LPA requested medical records on 03/03/2022 and received the records on 03/25/2022.


CONT 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20220218085027
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: RESERVE AT THOUSAND OAKS, THE
FACILITY NUMBER: 197609632
VISIT DATE: 06/01/2022
NARRATIVE
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Regarding the allegation, it was alleged that the facility failed to safeguard R1’s personal belongings, as an air mattress was ordered for R1 and R1 did not receive it in a timely manner. Interviews and records review revealed that due to R1’s stage two pressure injury, home health requested an order for an air mattress for R1 on 1/14/2022. Interviews revealed that it was delivered the evening of 1/14/2022 and that facility staff signed off for the air mattress. However, interviews revealed that although staff claimed to have signed for the mattress, staff were unable to locate the mattress after it was delivered on 1/14/2022. As a result, R1’s responsible party had to order a new air mattress for R1, and it was delivered on 1/18/2022. Upon arrival of the new mattress, the original mattress that was delivered on 1/14/2022 was found in R1’s room. Staff were unaware as to whether R1’s original mattress was always in R1’s room, or if the mattress was discovered after the 1/14/2022 and placed in R1’s room thereafter.

Staff speculated that R1’s mattress was overlooked, as it was ‘rolled up’ like a sleeping bag when it was initially discovered. However, the use of the air mattress was to offset pressure on R1’s coccyx pressure injury, and due to staff oversight, R1 was without the air mattress from 1/14/2022 – 1/18/2022.

Based on the information obtained, there is sufficient evidence to support the claim that staff failed to safeguard R1’s personal belongings. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):
Exit interview conducted. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220218085027
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: RESERVE AT THOUSAND OAKS, THE
FACILITY NUMBER: 197609632
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
87217(b)
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87217(b) Safeguards for Resident Cash, Personal Property, and Valuables Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Submit a Plan of Action, detailing how the facility will ensure that resident personal property is safeguarded. Submit plan to CCLD no later than POC due date of 6/10/2022.
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Based on the investigation, the licensee did not comply with the section cited above as it related to R1's air mattress, which poses a potential personal rights risk to residents in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6