197609814-8-4-2020-31-AS-MVAO-BS8NU7-20200806104552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609814
Report Date: 08/04/2020
Date Signed: 08/04/2020 09:53:49 AM

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
01/16/2020 and conducted by Evaluator Aja Richardson

COMPLAINT CONTROL NUMBER: 31-AS-20200116154421

FACILITY NAME:	LAND OF PEACE 2		FACILITY NUMBER:	197609814
ADMINISTRATOR:	ZAKHARYAN, TIGRAN		FACILITY TYPE:	740
ADDRESS:	6636 SALE AVENUE		TELEPHONE:	(818) 917-7211
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 6	DATE:	08/04/2020
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Sona Muradyan		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff handled resident in a rough manner resulting in injuries
Resident is not being repositioned by staff resulting in a wound
Staff are force feeding resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Aja Richardson conducted an unannounced visit to deliver the findings on the above allegations. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint visit was conducted telephonically with Sona Muradyan, the facility administrator.

Allegation #1: Staff handled resident in a rough manner resulting in injuries. To investigate this allegation, LPA Richardson conducted a visit on 1/24/20 and at 11:45 am began interviews with the Administrator, staff, residents in care, Resident #1(R1’s) hospice and home health agency. At 1pm on 1/24/20, the LPA reviewed and obtained copies of R1’s facility records. On 5/6/20, the LPA reviewed R1’s medical records, on 7/22/20, the LPA reviewed R1’s home health records, and on 7/23/2020 at 9:30 am, R1’s relative was interviewed. Based on interviews with staff, home health nurse, and other resident in care, staff were never observed being rough with resident #1 (R1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

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-20200116154421

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 2	FACILITY NUMBER: 197609814
	VISIT DATE: 08/04/2020

NARRATIVE

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In addition, home health was monitoring R1's skin integrity (2) times a week and never observed or documented any skin tears or bruising due to rough handling by staff.
Home Health Nurse also stated it is common for R1 skin to be fragile and sensitive to touch and facility staff denies handling R1 in a rough manner. At this time there is insufficient evidence that bruising or skin tears were due to staff being rough. This allegation is Unsubstantiated at this time.

Allegation #2: Resident is not being repositioned by staff resulting in a wound. To investigate this allegation, LPA Richardson conducted a visit on 1/24/20 and at 11:45 am began interviews with the Administrator, staff, residents in care, Resident #1(R1’s) hospice and home health agency. At 1pm on 1/24/20, the LPA reviewed and obtained copies of R1’s facility records. On 5/6/20, the LPA reviewed R1’s medical records, on 7/22/20, the LPA reviewed R1’s home health records, and on 7/23/2020 at 9:30 am, R1’s relative was interviewed.
According to the LPA record review and interviews, on 10/20/19, R1 began receiving services from Home Health. On 11/26/19, R1 began receiving wound care two (2) times a week due to documentation of Stage 2 pressure injury to R1’s buttocks. According to home health records on 12/9/19, there was no indication of any pressure injuries. However, on 12/30/19, R1 was noted to have a pressure injury on R1’s right buttock, though the stage of the pressure injury was not identified.

On 1/2/20, R1 was noted to have a right buttock pressure injury and a blister on R1’s right heel, which was not staged. On 1/9/20, the home health nurse documented that the wounds were not getting any better or worse; and, on 1/13/20, R1 was hospitalized due to sepsis. R1’s hospital records states that R1 had an unstageable pressure injury to R1’s right heel upon admission. R1’s relative observed R1 out of bed daily; and, when in bed, R1 was repositioned by staff throughout the day. Interviews with home health state stated that at no time were the pressure injuries unstageable; and, they were in constant communication with staff. Home health also stated that they worked well with the facility staff and believed that the staff were repositioning R1 every two (2) hours as requested. In addition, the facility staff stated that they were repositioning resident every two (2) hours and following any directives from home health. Due to the resident being under the care of home health, receiving consistent wound care and home health confirming the staff’ statements that they were repositioning resident as requested, this allegation is unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200116154421

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 2	FACILITY NUMBER: 197609814
	VISIT DATE: 08/04/2020

NARRATIVE

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Allegation 3: Staff are force feeding resident. To investigate this allegation, LPA Richardson conducted a visit on 1/24/20 and at 11:45 am began interviews with the Administrator, staff, residents in care, Resident #1(R1’s) hospice and home health agency. At 1pm on 1/24/20, the LPA reviewed and obtained copies of R1’s facility records. On 5/6/20, the LPA reviewed R1’s medical records, on 7/22/20, the LPA reviewed R1’s home health records, and on 7/23/2020 at 9:30 am, R1’s relative was interviewed. Based on interviews with staff, home health nurse, other resident in care, and R1's relative, staff were never observed force feeding resident. Based on record review and interviews, R1 was on a pureed diet and R1's relative would assist with feeding during lunch and dinner daily.

Based on interviews conducted there is insufficient evidence that staff were force feeding R1. Therefore, this allegation is Unsubstantiated at this time.

Exit Interview Conducted. Report Emailed. No deficiencies Cited.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

LIC9099 (FAS) - (06/04)

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