197609811-6-5-2021-31-AS-CHAS-C4FLWX-20210629090752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609811
Report Date: 06/05/2021
Date Signed: 06/05/2021 10:00:20 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
01/21/2021 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210121104029

FACILITY NAME:	LAND OF PEACE 6		FACILITY NUMBER:	197609811
ADMINISTRATOR:	ROSELIN FINULIAR		FACILITY TYPE:	740
ADDRESS:	22626 KITTRIDGE STREET		TELEPHONE:	(818) 884-2214
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 6	DATE:	06/05/2021
		UNANNOUNCED	TIME BEGAN:	07:10 PM
MET WITH:	Roselin Finuliar		TIME COMPLETED:	07:45 PM

ALLEGATION(S):

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Resident 1 (R1) sustained Unstageable Pressure injuries while residing at the facility.

INVESTIGATION FINDINGS:

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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with administrator ROselin Finuliar.

This investigation was conducted by Olivia Spindola, an Investigator with Community Care Licensing Division’s Investigations Branch.

Regarding the allegation of lack of care and supervision, it was reported that Resident 1 (R1) was admitted to the hospital with a severe wound to the sacrum/coccyx area. Additionally, it was reported that the pressure injury was unstageable.

On 2/11/2021, Investigator Spindola conducted interviews with administrator, assistant administrator, and facility staff. Additionally, Investigator Spindola subpoenaed records from 360 Home Health and West Hills Hospital. On 3/16/2021, an interview was conducted with R1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2021

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-20210121104029

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: LAND OF PEACE 6	FACILITY NUMBER: 197609811
	VISIT DATE: 06/05/2021

NARRATIVE

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Based on a review of records received, R1 received medical care at West Hills Hospital and Medical Center (WHH/MC) and 360 Home Health. R1 was hospitalized on 1/5/2021 and discharged on 1/16/2021. R1 was released from WHH/MC to West Hills Rehabilitation Center after the facility administrator refused to re-admit R1 back from the hospital due to R1 having developed an unstageable pressure injury while hospitalized. Although WHH/MC medical records indicate R1 has a stage 1 pressure injury upon admission, the wound deteriorated as stated in the hospital notes. Furthermore, 360 Home Health provided care for R1’s stage I pressure injury from 11/10/2020 until his hospitalization. On 3/13/2021, R1 returned to live at the facility under hospice after he was released from the rehabilitation center. During the investigation, Investigator Spindola was not able to obtain information that R1 was neglected by the facility staff, therefore the allegation is unsubstantiated.

Exit interview conducted with the administrator and copy of report emailed.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2021

LIC9099 (FAS) - (06/04)

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