197609639-5-30-2024-29-AS-KLOZ-D5SSHW-20240531135414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609639
Report Date: 05/29/2024
Date Signed: 05/30/2024 07:29:51 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/18/2024 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20240118120829

FACILITY NAME:	ANA'S RESIDENCE CARE FACILITY		FACILITY NUMBER:	197609639
ADMINISTRATOR:	ANNA ATAYAN		FACILITY TYPE:	740
ADDRESS:	7747 VAN NOORD AVE		TELEPHONE:	(323) 688-3377
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Anna Atayan		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff caused an injury to a resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Anna and explained the reason for the visit.
On 01/18/2024, the Department received a complaint alleging Neglect/Lack of Care and Supervision regarding Resident #1 (R1). The complaint alleged Staff #1 (S1) failed to provide supervision to R1 resulting in R1 sustaining a fracture. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Heidy Bendana.
On 01/19/2024, from 10:30am to 12:05pm, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial visit to investigate the allegation listed above. LPA Urena arrived at 10:30am and was greeted by staff who contacted the licensee/administrator Anna Atayan. The LPA explained the reason for the visit and the licensee/administrator arrived shortly thereafter. At 11:00am the LPA requested records pertaining to the investigation. At 11:15am the LPA interviewed the licensee/administrator. The LPA determined further investigation was needed before delivering the findings.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 5

Control Number 29-AS-20240118120829

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANA'S RESIDENCE CARE FACILITY	FACILITY NUMBER: 197609639
	VISIT DATE: 05/29/2024

NARRATIVE

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Pg. 2
On 02/08/2024, from approximately 9:43am to 10:53am, Investigator Bendana conducted interviews with residents, R1, licensee/administrator, and staff; on 03/11/2024, at approximately 2:43pm, with S1; on 04/15/2024, at approximately 9:20am, with R1’s resident representative; and on 04/17/2024, at approximately 2:54pm, with the reporting party. In addition, Investigator Bendana reviewed Glendale Adventist Medical Center medical records, Palermo Hospice medical records, and facility file documents related to R1.

According to the facility file documents reviewed, R1’s physician’s report, signed and dated by the physician on 07/10/2023, listed R1’s primary diagnosis as heart disease, dementia, and muscle weakness. It is noted R1 has mild cognitive impairment with an unsteady gait. R1 is confused and disoriented at times but can communicate and follow instructions. R1 needs assistance with activities of daily living (ADLs), is non-ambulatory, not able to transfer to and from bed, and uses a walker. Under the comments, it is noted that R1 is a fall risk and needs maximum assistance. R1’s appraisal needs and services plan, dated 08/01/2021, also indicated R1 needed assistance with ADLs, and needed assistance moving around the facility due to poor functioning body and needs full assistance in using functioning skills. The preplacement appraisal information for R1, dated 07/25/2021, listed R1 cannot ambulate independently due to muscle weakness.

The investigation revealed that R1 had been a resident at the facility for approximately three years and had been frequently getting UTIs (urinary tract infections). On 01/06/2024, the licensee/administrator called R1’s resident representative to inform that R1 was “confused” and suggested “maybe” R1 needed medical care. R1 complained about pain in the “abdominal area and back” which R1 complained about when R1 had UTIs. R1’s resident representative then came to the facility to find R1 in excruciating pain and transported R1 to the Glendale Adventist Medical Center.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20240118120829

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANA'S RESIDENCE CARE FACILITY	FACILITY NUMBER: 197609639
	VISIT DATE: 05/29/2024

NARRATIVE

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Pg. 3
A review of the medical records indicated R1 was admitted to Glendale Adventist Medica Center on 01/06/2024 with the chief complaint of back/abdominal pain, nausea, vomiting and confusion. History of UTIs, hypertension, dyslipidemia presented to the emergency room with altered mental status. Patient (R1) was brought into the emergency department for generalized weakness, more altered than usual, with chills and weakness, abdominal pain. A CT scan without contrast of the abdomen/pelvis was conducted which revealed an acute T11 compression fracture. On 01/10/2024, R1 was discharged with a diagnosis of Covid-19 virus infection; altered mental status, and UTI.

A review of the Palermo Hospice medical records indicated R1 was placed on hospice care at the facility on 01/11/2024. The records listed the chief complaint as chronic ischemic heart disease. R1 was also listed as non-ambulatory, bed bound, or wheelchair needed maximum assist, and a high fall risk.

The information obtained from interviews revealed that the licensee stated R1 did not have any falls but that maybe R1 suffered the fracture on the way to the hospital, at the hospital, or maybe at the facility. The facility staff denied that R1 had any falls. S1 claimed R1 did not fall. S1 explained when assisting R1, R1 stated they were in pain, R1’s “back” was “hurting” and did not want to “get up.” S1 said they did not know if R1 was given pain medicine; it was “not” S1’s “responsibility” to “give” R1 medicine. S1 claimed R1 did not have a fall under S1’s care and could not explain why R1 was in pain. S1 remembered R1 complained of pain “all day.” S1 stated S1 informed the licensee/administrator who then notified R1’s resident representative. The investigation further revealed that R1 reported to R1’s resident representative, that S1 dropped R1 while assisting R1 in the bathroom. R1 reported that “S1 dropped them, they fell on their butt, and it really, really hurts”. Furthermore, the CT scan at the hospital revealed R1 sustained a T11 compression fracture.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20240118120829

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANA'S RESIDENCE CARE FACILITY	FACILITY NUMBER: 197609639
	VISIT DATE: 05/29/2024

NARRATIVE

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Pg. 4
On the allegation “Staff caused an injury to a resident while in care” - the Department’s investigation provided sufficient evidence to substantiate neglect/lack of supervision. Medical records showed R1 sustained a T11 compression fracture. R1 reported S1 “dropped” R1. R1 stated they complained of pain. R1’s resident representative stated R1 was in “excruciating pain” and would scream when R1 was moved or tried to move. The licensee/administrator stated R1 may have fallen at the facility. S1 failed to adequately assist R1 resulting in R1 sustaining a T11 compression fracture, therefore, the allegation is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20240118120829

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANA'S RESIDENCE CARE FACILITY	FACILITY NUMBER: 197609639
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/14/2024 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan how you will ensure appropriate care and supervision to meet the needs of residents. Submit to CCL by 06/14/2024.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above. S1 failed to adequately assist R1 resulting in R1 sustaining a T11 compression fracture while in care, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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