197609641-1-18-2022-29-AS-DPEA-CCZSSY-20220330140841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609641
Report Date: 01/18/2022
Date Signed: 01/18/2022 04:19:44 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210430105609

FACILITY NAME:	COMMONS AT WOODLAND HILLS, THE		FACILITY NUMBER:	197609641
ADMINISTRATOR:	STEWART, BRADLEY		FACILITY TYPE:	740
ADDRESS:	21711 VENTURA BLVD		TELEPHONE:	(818) 999-2610
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY:	200	CENSUS: 102	DATE:	01/18/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Hannah Meyers		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Neglect/Lack of Supervision – Former Resident #1 (R1) had multiple falls while sustaining serious multiple injuries within a 24-hour period in the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 05/05/2021 by LPA Brian Balisi. During today’s visit, LPA Balisi met with Hannah Meyers and explained the reason for the visit.

On 04/30/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. Former Resident #1 (R1) had multiple falls while sustaining serious multiple injuries within a 24-hour period in the facility. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Philippe Ryan Miles.

On 05/05/2021, between 10:00am and 12:00pm, LPA Balisi conducted the initial complaint visit and met with Executive Director Sophia Lukas and Assistant Executive Director Hannah Myers and explained the reason for the visit. LPA conducted a physical plant tour with Assistant Executive Director Myers and obtained copies of documents pertinent to the allegation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

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 29-AS-20210430105609

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: COMMONS AT WOODLAND HILLS, THE	FACILITY NUMBER: 197609641
	VISIT DATE: 01/18/2022

NARRATIVE

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Continued from 9099

Investigator Miles conducted interviews with R1’s Representative on 07/27/2021 at approximately 9:06am; with the current Executive Director Hannah Myers, Assistant Living Director, activity assistant, and caregivers from approximately 11:39am to 1:59pm; with caregivers on 07/29/21, from approximately 2:35pm to 3:45pm; with R1 and a witness on 08/03/2021, from approximately 11:45am to 11:49am. Additionally, Investigator Miles obtained and reviewed facility records and medical records.

Information gathered reflected R1 was admitted to the Assisted Living portion of the facility on 04/22/2017. The pre-placement appraisal indicated R1 used a walker and wheelchair and was a high fall risk. Per the Community Census Detail Report, R1 began services in the memory care unit on 03/10/2021. R1 required an extensive level of assistance in mobility and ambulation as well as moderate assistance with toileting. Facility progress notes revealed that R1 had a fall on 03/21/2021 which required 1^st aid for skin tears to both arms; found on the floor on 04/17/2021 and found on the bathroom floor on 04/21/2021 with no visible injuries; and a fall in the hallway on 04/24/2021 and on bathroom floor on 04/25/2021 sustaining head injuries and requiring visits to Northridge Hospital and Kaiser Permanente. Facility notes dated 04/21/2021, noted that R1 had been having changes in behavior for the past few months, specifically at night. R1 had been getting up in the middle of the night with agitated behavior, and at times acted aggressive with staff. R1 had been prescribed medication for anxiety and the adjustment of R1’s medication from the physician was requested.

Per the medical records, R1 had a history of falls and was previously admitted to Northridge Hospital for a fall that occurred in the facility on 03/19/2021. On 04/24/2021, R1 was found on the hallway floor. R1 fell and hit back of head on floor. R1 was taken to Northridge Hospital and discharged back to the facility at 3:00am on 04/25/2021. An hour later, at 4:00am, R1 was readmitted to Northridge Hospital by ambulance after staff found R1 on the bathroom floor with head bleeding. The CT scan performed on R1’s head found a subdural hematoma. The scalp laceration was repaired by the Emergency Room Department. R1 was stabilized and transferred to Kaiser Permanente for observation. On 04/27/2021, R1 was admitted to Kaiser Permanente with the diagnosis of traumatic subdural hematoma. R1 was evaluated by Neurosurgery and it was determined R1 was not an operative candidate. On 05/07/2021, R1 was transferred to a Skilled Nursing Facility.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210430105609

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: COMMONS AT WOODLAND HILLS, THE	FACILITY NUMBER: 197609641
	VISIT DATE: 01/18/2022

NARRATIVE

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Continued from 9099-C

Information obtained through facility staff interviews found that the facility was unable to provide R1 the adequate care and supervision and that R1 needed a higher level of care and supervision. Based on the interviews conducted, R1 was not provided the proper level of care and supervision, resulting in repeated unwitnessed falls in the facility; therefore, the allegation of Lack of Care and Supervision is Substantiated at this time.

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

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)
Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20210430105609

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: COMMONS AT WOODLAND HILLS, THE	FACILITY NUMBER: 197609641
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 01/19/2022 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	Every facility required to be licensed under this chapter shall provide at least the following basic services: (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 agree to submit plan to provide proper level of care and supervision to ensure resident needs are met. Submit to CCLD via email by end of buisnes 1/19/2022.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above. Licensee failed to provide adequate care and supervision due to R1 needed a higher level of care which resulted in R1’s sustaining multiple falls causing a head injury, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
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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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

LIC9099 (FAS) - (06/04)

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