197609641-12-21-2021-31-AS-DPEA-C9ZRNX-20211224121104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609641
Report Date: 12/21/2021
Date Signed: 12/21/2021 04:30:56 PM

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
01/31/2020 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20200131143649

FACILITY NAME:	COMMONS AT WOODLAND HILLS, THE		FACILITY NUMBER:	197609641
ADMINISTRATOR:	STEWART, BRADLEY		FACILITY TYPE:	740
ADDRESS:	21711 VENTURA BLVD		TELEPHONE:	(801) 815-0808
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY:	200	CENSUS: 104	DATE:	12/21/2021
		UNANNOUNCED	TIME BEGAN:	03:47 PM
MET WITH:	Hannah Myers		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Due to facility neglect/lack of supervision, Resident #1 (R1) was hospitalized with multiple bruises

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 02/03/2020 by LPA Eva Miller. During today’s visit, LPA Camara met with Executive Director Hannah Myers and explained the reason for the visit.

On 01/31/2020 the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was reported that Resident #1 (R1) was admitted to the hospital on 01/27/2020 and was discovered to have multiple bruises in varying stages of healing throughout body, including R1’s labia majora, and the origin of these bruises may have resulted from facility neglect. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Jose Santana.

(continued on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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-20200131143649

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: 12/21/2021

NARRATIVE

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On 02/03/2020, between 11:15 a.m. and 12:15 a.m., LPA Miller conducted the initial complaint visit and met with Administrator/Executive Director, Bradley Stewart. LPA conducted a review of facility records and requested copies of documents pertinent to the allegation and noted further investigation would be required.

Investigator Santana conducted interviews with Los Angeles Police Department (LAPD) Topanga Community Station Detective on 02/05/2020 and 02/20/2020; with the reporting party, R1, and Administrator/Executive Director Bradley Stewart on 02/07/2020; with Region II Long Term Care Ombudsman Program (LTCOP) on 02/10/2020 and 03/19/2020; with Palliative Care Licensed Clinical Social Worker (LCSW) at Providence Tarzana Medical Center (PTMC) on 02/14/2020; with Assisted Living Director Mary Ty, facility medication technician, and caregiver on 02/18/2020; with Registered Nurse (RN) at PTMC on 02/19/2020; with R1’s responsible party on 02/20/2020; with MedQuest Health Services, R1’s attending physician at PTMC, and R1’s family member on 02/24/2020; with Diagnostic Radiology Specialist at PTMC , Administrator/Executive Director Bradley Stewart, facility med technicians, and caregivers on 02/27/2020; with R1’s family member, residents, and caregiver on 03/09/2020; and with R1’s admitting physician at PTMC on 03/13/2020. Additionally, Investigator Santana obtained and reviewed facility records, medical records and emergency medical services (EMS).

Information gathered reflected, R1 diagnoses include dementia, polycythemia vera, osteoporosis, gait abnormality, and a history of falling. R1 moved into the facility on 12/18/2018 after being discharged from Topanga Terrace Skilled Nursing Facility (SNF), where R1 had been admitted since 10/16/2018 due to a fractured left femur. R1 requires assistance of one person for activities of daily living (ADL’s), including transferring and ambulating/escorting. While residing at the facility, R1 sustained a fractured right femur in April 2019 and has been found on the floor numerous times since then.

Per the facility records, R1 was a fall risk, required assistance with transferring/ambulation, and had a history of trying to get out of bed unassisted. Based on facility statements and facility records, R1 exhibited confusion on the afternoon of 01/26/2020 and continued attempting to get out of bed on own, so R1 was monitored closely. A caregiver found R1 on the floor that evening, but R1 was not sent out for medical evaluation because there were no visible injuries. A medication technician believed R1 might have a urinary tract infection, and per a facility physician’s verbal orders, a urine sample was obtained for next day retrieval for testing.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200131143649

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: 12/21/2021

NARRATIVE

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On 01/27/2020 at 1:00 a.m., R1 was again found on the floor but was not sent to the hospital for evaluation because a medication technician assessed and believed there were no injuries. It was not until the mid-morning of 01/27/2020, that the facility sought medical attention for R1 because R1 exhibited greater confusion and shortness of breath. The facility noted no visible injuries on R1 at that time except for discoloration on knees from a previous fall, but the hospital noted a fractured pubic bone and swollen gluteus, both on the right side. Upon examination and testing, R1 was diagnosed with leukocytosis, elevated lactic acid level, pneumonia, severe sepsis, urinary tract infection, pelvic mass, and a closed nondisplaced fracture of the pelvis. It was also noted that R1 had a history of COPD, high blood pressure and leukemia. R1’s CT scan showed a large lobulated pelvic mass, right pubic bone fracture and multiple thoracic and lumbar compression fractures. Per R1’s admitting physician, it is more likely that these injuries were a result of a possible fall rather than from the pubic mass the hospital discovered, the latter of which likely caused R1’s labial bruising and vaginal bleeding. A radiologist confirmed the pelvic fracture was acute.

On 01/28/2020 at 4:27 a.m., the Registered Nurse (RN) noted multiple bruises to R1’s bilateral knees, left foot, and groin. It was also noted R1 had bloody discharge, possibly from vaginal bleeding. A pelvis ultrasound performed at 2:02 p.m. found that R1 had an enlarged, lobulated fibroid uterus which correlated with the CT scan finding from 01/27/2020. At 2:26 p.m., the RN documented R1’s right labia majora was swollen with a dark purple bruise, a large purple bruise on R1’s left lateral knee, a large yellow bruise on right lateral thigh, and other, smaller bruises on R1’s arms and legs. R1 was placed on hospice on 02/04/2020 and returned to the facility under Assisted Hospice Care.

Based on R1’s change in condition between 01/26/2020 and 01/27/2020, as documented in facility records, and evidenced by medical records, the facility failed to adequately address R1’s confusion, and this contributed to the injuries sustained. The allegation “Due to facility neglect/lack of supervision, Resident #1 (R1) was hospitalized with multiple bruises” is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Executive Director 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200131143649

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: 12/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 12/22/2021 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	§1569.312(a) Basic services requirements. 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 will submit plan to provide proper level of care and supervision to ensure resident needs are met. Submit to CCL by 12/24/2021.
	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 adequately address R1’s confusion, and this contributed to the injuries sustained, 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC9099 (FAS) - (06/04)

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