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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609736
Report Date: 10/07/2021
Date Signed: 10/07/2021 12:16:15 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/10/2020 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20200310083928
FACILITY NAME:TUJUNGA CANYON BOARD & CAREFACILITY NUMBER:
197609736
ADMINISTRATOR:ANAHIT MARTIKYANFACILITY TYPE:
740
ADDRESS:9522 TUJUNGA CANYON BLVDTELEPHONE:
(818) 335-0787
CITY:LOS ANGELESSTATE: CAZIP CODE:
91042
CAPACITY:6CENSUS: 0DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Aram Petrosian TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident has multiple stage IV pressure injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegation. Upon arriving at the facility on 10/7/21 LPA observed it to be closed and all residents to be relocated. LPA was let into the facility to inspect it by the administrator's husband, who signed for this report.

The Complainant alleged that Resident #1 (R1) was admitted to the Hospital on 3/5/21 with diagnoses including but not limited to multiple Stage IV Pressure Injuries; thus indicating that the facility had Admitted and/or Retained a resident with a Prohibited Health Condition and that the condition escalated due to insufficient care.
During the investigation, LPA conducted a visit and interviewed the administrator and staff 1 (S1) on 3/11/20; reviewed client records for resident 1 (R1) submitted to LPA by the administrator on 3/12/20 and 3/13/20; reviewed hospital intake and wound care paperwork for from USC Verdugo Hills Hospital for R1 for the period of 3/5/20-3/6/20; interviewed R1’s responsible party and reviewed R1’s death certificate on 9/23/21.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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 3
Control Number 31-AS-20200310083928
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TUJUNGA CANYON BOARD & CARE
FACILITY NUMBER: 197609736
VISIT DATE: 10/07/2021
NARRATIVE
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In reference to the allegation “Resident has multiple stage IV pressure injuries,” The information obtained during the investigation determined the following: The Home Health wound assessment from 2/26/20 documented Stage IV Pressure Injuries, a Prohibited Health Condition. There was no documentation or evidence indicating R1 was receiving Hospice Services. R1 was retained at the facility with the Prohibited Health Condition from at least 2/26/20 until R1 was admitted to the hospital. On 3/11/20, during interview, administrator stated to LPA that R1 was currently at the hospital and had been admitted for stage IV pressure injuries. Administrator stated that R1 had been receiving Home Health Agency services for wound care but confirmed that R1 was not receiving hospice services. Wound care notes submitted by the administrator for R1 on 3/13/20 indicated that R1 received wound care treatment from Omni Wound Care on 2/26/20 at the facility, which consisted of a “scalpel debridement” of stage IV pressure injuries on the left and right heels. Under R1’s “Plans/Orders” for that visit, it was noted: “change dressing daily or PRN if soiled or there is a loss of integrity. Patient's nurse states that she can change dressings on days that HHA nurse cannot come."

The next record of wound care service provided by administrator was from 3/4/20 and indicated that the patient was unable to tolerate debridement on that day. Under Plans/ Orders, it stated: “Change dressing daily or PRN if soiled or there is loss of integrity. Patient's nurse states that she can change dressings on days that HHA nurse cannot come...We will sign off on this patient as he is not tolerating gentle sharp debridement and is noncompliant during treatment”

Records obtained from USC Verdugo Hills Hospital indicated that R1 was admitted to the Emergency Room on 3/5/20 at 11:30 PM. R1’s Initial Wound Care Consult conducted on 3/6/20 at 12:45pm indicated that R1 was “moaning with pain during assessment,” and ultimately found to have unstageable pressure injuries on the “right trochanter”, “right heel”, and “left heel”.

Based on the information obtained during records review and interviews, LPA has determined that the allegation is substantiated. LPA further determined that the Deficiencies resulted in injury and/or illness to a resident or residents in care which the Department views with Zero Tolerance. A civil penalty of $500.00 is warranted.
Report reviewed, signed and delivered. Exit interview conducted, deficiencies cited on 9099D page, appear rights provided, and civil penalties assessed.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20200310083928
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TUJUNGA CANYON BOARD & CARE
FACILITY NUMBER: 197609736
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2021
Section Cited
CCR
87615(a)
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87615(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(1) Stage 3 and 4 pressure injuries.
This requirement is not met as evidenced by:
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The facility has ceased operation at this time. Administrator will pay the civil penalty issued in this complaint, and confirm with LPA their intentions for the facility by the indicated date. Admin will either surrender their license to finalize closure, or provide proof of attending training on prohibited health conditions from
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Based on records reviewed and interviews conducted, the facility did retain a resident with a prohibited health condition which poses an immediate risk to the health, safety or personal rights of residents in care.
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an approved vendor.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3