197609786-3-28-2022-29-AS-JAPL-CCY36B-20220328175804

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609786
Report Date: 03/24/2022
Date Signed: 03/28/2022 12:00:05 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
05/22/2020 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20200522094856

FACILITY NAME:	WOODLAND HILLS RETIREMENT HOME		FACILITY NUMBER:	197609786
ADMINISTRATOR:	KALISTRATOV, SERGUEI		FACILITY TYPE:	740
ADDRESS:	24301 OXNARD ST		TELEPHONE:	(818) 564-4381
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	03/24/2022
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Serguei Kalistratov		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained several pressure injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit on 03/24/2022 to deliver findings for the above allegation. The initial visit was conducted on 05/26/2020 by LPA Aja Richardson telephonically via a video chat and a subsequent visit was conducted on 03/15/2022 by LPA Camara. During today’s visit, the LPA met with the facility administrator, Serguei Kalistratov and explained the reason for the visit.

On 05/22/2020, the Department received a complaint regarding the allegation Resident #1 (R1) sustained multiple pressure injuries while in care. Some of these pressure injuries were first noted by Medical Center staff upon initial exam on 05/20/2020.

(continued on 9099-C)

Unsubstantiated

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: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

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-20200522094856

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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
	VISIT DATE: 03/24/2022

NARRATIVE

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On 05/26/2020, between 2:45 p.m. and 3:15 p.m., LPA Richardson conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically. At 2:45 p.m., the LPA conducted an interview and physical plant tour via video call with facility administrator Serguei Kalistratov. At 3:00 p.m., the LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required.

On 05/26/2020, LPA Richardson ordered the following records:

- home health records from R1’s Home Health Agency

- medical records from the hospital for R1’s admission on 05/14/2020

- medical records from the Medical Center for R1’s admission on 5/20/2020

On 10/17/2020, LPA Richardson conducted telephonic interviews with the administrator at 10:00 a.m. and R1’s responsible party (RP) at 1:00 p.m. The RP indicated R1 was originally admitted to the facility with wounds and received wound care from the home health agency. The RP had concerns about facility staff not repositioning R1 frequently enough or providing incontinence care at night because the night shift staff slept at the facility. The RP stated that after R1’s stay at the hospital on 05/14/2020 through 05/18/2020, R1 returned to the facility in worse condition. The RP stated R1 was admitted to the Medical Center for further care on 05/20/2020. The RP was aware R1 had developed more pressure injuries but could not say if they developed at one of the hospitals or the facility. The administrator stated R1 was released from the Medical Center on 05/26/2020 on hospice and R1 passed away on 06/04/2020.

During LPA Camara’s visit to the facility on 03/15/2022 between 12:15 p.m. and 1:27 p.m., LPA Camara interviewed a visitor at the facility at 12:17 p.m., conducted a brief plant tour at 12:26 p.m., and interviewed the administrator at 12:45 p.m. The administrator stated he was the primary caregiver for R1; he ensured he and the staff kept R1 clean and repositioned as per the home health nurse directions. Due to the age of R1’s records, they were no longer stored at the facility. The administrator was asked to bring R1’s records, including hospice records, to the Community Care Licensing (CCL) office in Woodland Hills the following day. On 03/16/2022, the administrator came to the CCL office with R1’s records, however the administrator did not

(continued on 9099-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200522094856

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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
	VISIT DATE: 03/24/2022

NARRATIVE

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have any hospice records for R1. The administrator stated he recalled the home health agency provided the hospice services.

On 03/22/2022, LPA Camara contacted the home health agency to obtain information about hospice care services. LPA was informed that the agency only provides home health services, they are not a hospice agency. They already provided all of the records they have for R1.

Information gathered reflected R1 was initially admitted to the facility on 05/01/2020 from a skilled nursing facility. R1 was evaluated by home health on 05/02/2020 and it was noted R1 had a skin tear on the right lateral arm and two Stage 2 pressure injuries: one on R1’s coccyx and one on R1’s left heel. R1 received wound care from the home health agency on the following dates: 05/02/2020, 05/05/2020, 05/08/2020, 05/11/2020, and 05/14/2020.

On the evening of 05/14/2020, facility staff called 9-1-1 for R1 due to R1’s altered mental state. R1 was admitted to the hospital and was diagnosed with sepsis and unstable angina. R1 was released from the hospital on 05/18/2020 with a recommendation to consider hospice. There was no mention of the state of R1’s wounds/skin in the hospital records upon R1’s release and the facility administrator did not complete a reappraisal.

On 05/20/2020, R1 was experiencing confusion and dehydration due to diarrhea. R1 was sent to the Medical Center and admitted. The Medical Center noted several pressure injuries/redness: coccyx, left heel, right hip, right lateral back, right lateral foot, right lateral ankle, redness on groin, and penial swelling. (Note: The Medical Center did not note the stage of the wounds.) R1 was released from the Medical Center on 05/26/2020 with instructions to contact hospice within 24 hours. The administrator did not complete a reappraisal, nor did the administrator have any information regarding which hospice agency provided services to R1.

Based on the home health and hospital records, it was unclear where R1’s new pressure injuries occurred since R1 had just recently been released from a hospital inpatient stay and it was unclear if the two original wounds on the coccyx and left heel had advanced beyond Stage 2. In addition, R1 was under the care of home health prior to R1’s two hospital stays. There was no indication in home health records of the wounds worsening or that facility staff were not following their directions. As a result, there is insufficient evidence to confirm that R1 developed pressure injuries due to facility staff neglect; therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of the 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: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC9099 (FAS) - (06/04)

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