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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609632
Report Date: 07/14/2023
Date Signed: 07/14/2023 02:18:51 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2023 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20230127104251
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: 128DATE:
07/14/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth SpencerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Insufficient staffing
Resident sustained injuries from a fall while in care
Resident are left unattended for an extended amount of time
Staff do not respond timely to the residents alerts
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Elizabeth Spencer and explained the reason for the visit.

On1/30/2023, the LPA conducted staff interviews from 9:45 a.m. – 12:00 p.m., and collected pertinent documents. On 7/10/2023, the LPA conducted staff and resident interviews from 10:00 a.m. – 3:15 p.m. Additional resident interviews took place on 07/12/2023 from 10:00 a.m. – 11:15 a.m., and additional staff interviews took place on 7/13/2023 at 11:50 a.m. and 12:12 p.m. Today, the LPA conducted resident and staff interviews between 10:00 a.m. - 2:00 p.m.


CONT on 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: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
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 4
Control Number 29-AS-20230127104251
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: 07/14/2023
NARRATIVE
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Regarding the allegation: Facility has insufficient staff for the residents while in care


It was alleged that the facility was severely understaffed. Interviews and records indicated that fully staffed meant there were at least two medication technicians and three to four caregivers for the AM shift (6 a.m. – 2 p.m.) and PM shift (2 p.m. – 10 p.m.). At times, there is only one (1) medication technician in the PM shift. Staffing is also based on the needs of the current residents within the facility. Staff admitted that at times, if someone calls off, staff will need to supplement with agency staff, assign a medication technician to also conduct caregiving duties, or management staff will step in. Staff interviews confirmed that in January 2023, management staff had to step in and conduct caregiving duties for certain shifts due to staff calling off work. Although some staff indicated that additional staff members were needed, the majority of staff felt that there was sufficient coverage to manage resident care needs. Similarly, most residents interviewed indicated that care needs have not suffered or gone unmet due to staffing concerns. The LPA reviewed pendant logs from 06/15/2023 – 07/10/2023 and uncovered that generally, staff respond to resident pendant calls within 4-8 minutes. Whereas there were some response times that went between 10-15 minutes, it was not most of the pendant calls and represented sporadic occurrences. Based on the information obtained in interviews and record review, there is insufficient evidence to support the claim that facility has insufficient staff for residents while in care. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident sustained injuries from a fall while in care


It was alleged that due to neglect, Resident #1 (R1) sustained injuries from a fall. Records indicated that on 01/26/2023, R1 suffered an unwitnessed fall in their room. Due to the fall, R1 had a large skin tear on their left hand. When 9-1-1 arrived and R1 was being assisted onto the gurney, records indicated R1 collapsed on the floor and suffered an additional skin tear on the right leg. R1’s needs and services plan indicated R1 was a fall risk, required escorting to meals and activities, needed reminders to use their cane and walker if observed ambulating without the device, and R1 required reminders to ask for assistance when ambulating. Regarding toileting, R1’s plan documented that staff had to assist R1 with changing their briefs when necessary. A review of charting notes for R1 documented that on 01/07/2023, R1 complained of pain and stated that they tried to go to the bathroom and had almost fallen. Due to weakness, R1 was sent to the hospital. R1 was discharged back to the facility on 01/11/2023, and it was documented that R1 reported that they would ‘press [the] pendant if [they] were not feeling well and when [R1] needed to use the restroom’.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20230127104251
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: 07/14/2023
NARRATIVE
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Interview and record review noted that during R1's hospitalization from the 01/26/2023 incident, staff visited R1 in the hospital on 1/31/2023. Staff stated R1 reported pressing their pendant because they had to use the restroom, but R1 got up and attempted to the restroom despite having pressed the pendant and subsequently fell. R1 allegedly reported that they would wait until staff arrive when they press their pendant for assistance. R1’s charting notes did not reveal that R1 had regular incidents when they would fall while ambulating despite needing staff assistance Resident interviews noted that most residents felt staff were responsive when pressing their pendant. Residents indicated that even in times where they fell or required medical attention and pressed their pendant, residents claimed that staff had been timely in responding to the pendant. Residents also denied ever being left unattended or soiled for an extended period.

Based on information obtained in interviews and records review, there is insufficient evidence to support the claim that due to neglect, R1 sustained injuries from a fall. Although R1 suffered injuries from a fall, R1 alleged they attempted to go to the restroom after pressing their pendant for assistance. R1 had been reminded to use the pendant for assistance, and per the needs and services plan, R1 required changing briefs ‘as needed’. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Regarding the allegation: Residents are left unattended for an extended period of time while in care


It was alleged that due to neglect, Resident #1 (R1) fell and was left unattended for an extended period of time. Records indicated that on approximately 01/26/2023, R1 suffered an unwitnessed fall in their room. As a result of the fall, R1 suffered a large skin tear on their left hand. When 9-1-1 arrived and R1 was being assisted onto the gurney, records indicated that R1 collapsed on the floor and suffered an additional skin tear on the right leg. Staff indicated that when a resident presses their pendant, a staff member must ‘acknowledge’ the pendant on the facility pager (which is time stamped), but it is not until the staff physically see the resident that they can reset the resident’s pendant, which then indicates that they have ‘responded’ to it. In addition, the staff who acknowledges the pendant isn’t always the staff that responds to the pendant in person. Staff interviews and a review of R1’s pendant logs from 1/26/2023 indicated that R1 had pressed their pendant at 11:47 a.m. and although R1’s pendant had been acknowledged by staff within 1 minute and 35 seconds, staff were unable to respond to R1’s pendant for fifteen (15) minutes.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20230127104251
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: 07/14/2023
NARRATIVE
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PAGE 4

The LPA reviewed pendant response times from 01/26/2023 and noted that most of the response times were around eight (8) minutes. Further interview and record review noted that R1 was hospitalized, and staff visited R1 in the hospital on 1/31/2023. Staff stated R1 reported pressing their pendant because they had to use the restroom, but R1 got up and attempted to the restroom despite having pressed the pendant and subsequently fell. Additional resident interviews noted that most residents felt staff were responsive when pressing their pendant for assistance. Residents indicated even in times where they had fallen or required medical attention and pressed their pendant, staff had been timely in responding to the pendant. Residents also denied ever being left unattended or soiled for an extended period. Based on information from interviews and records review, there is insufficient evidence to support the claim that residents are left unattended for an extended period of time. Regarding the 01/26/2023 incident, there is no indication as to when R1 fell within the 15-minute time frame of pressing their pendant and receiving a response from staff. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Regarding the allegation: Staff do not respond timely to the resident alerts


It was alleged that residents were waiting for an extended amount of time to receive assistance. Most residents indicated that staff were responsive when pressing their pendant for assistance. Residents indicated that even in times where they had fallen or required medical attention and pressed their pendant, residents claimed that staff had been timely in responding to the pendant. The LPA reviewed pendant logs from 06/15/2023 – 07/10/2023 and uncovered that generally, staff respond to resident pendant calls within 4-8 minutes. Whereas there were some times that went between 10-15 minutes, it was not most of the calls and represented sporadic occurrences. Staff claimed that it may take time to respond to a call if they are assisting another resident with changing, toileting, or a shower. However, staff noted that they communicate with other caregivers if they are unable to respond to a resident pendant to ensure that someone is available to reach the resident in a timely fashion. Based on information obtained in interviews and records review, there is insufficient evidence to support the claim that staff did not respond timely to the resident alerts. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is 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: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4