197609845-7-11-2024-29-AS-KHEN-D9ERWY-20240924132355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609845
Report Date: 07/11/2024
Date Signed: 07/11/2024 03:58:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/29/2024 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20240129144129

FACILITY NAME:	SWEET HOME SENIOR LIVING FACILITY		FACILITY NUMBER:	197609845
ADMINISTRATOR:	KAREN BABAYAN		FACILITY TYPE:	740
ADDRESS:	6456 VARNA AVENUE		TELEPHONE:	(818) 666-7598
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	07/11/2024
		UNANNOUNCED	TIME BEGAN:	03:09 PM
MET WITH:	Lusine Srmikyan, Licensee		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility retained resident with a prohibited health condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 3:09 p.m., the LPA met with the Licensee and explained the reason for the visit.

During the initial visit on 1/30/2024, between 9:25 a.m. and 10:45 a.m., LPA Peraldi conducted a facility tour and reviewed records and obtained copies of pertinent documents. The LPA also conducted an interview with the Licensee. On 02/22/2024, the LPA conducted an interview with Resident #1 (R1’s) Home Health. On 2/23/2024, the LPA conducted a file review of Resident #1 (R1’s) documents such as but not limited to, admission agreement, and medical records. On 03/13/2024, the LPA conducted a subsequent visit between 2:45 p.m. and 3:25 p.m. and conducted an interview with R1 and received copies of pertinent documents. Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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-20240129144129

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SWEET HOME SENIOR LIVING FACILITY	FACILITY NUMBER: 197609845
	VISIT DATE: 07/11/2024

NARRATIVE

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Regarding the allegation: Facility retained resident with a prohibited health condition. On 01/29/2024, the Department received a complaint alleging that the Licensee admitted Resident #1 (R1) to the facility with an unstageable wound/ ulcer. R1 was admitted to Sweet Home Senior Living Facility on 01/26/2024. Prior to living at the facility, R1 was admitted to Country Villa Sheraton Nursing Center, a Skilled Nursing Facility (SNF) from 12/28/2023 to 01/26/2024. R1 was admitted to the SNF for rehab, and received physical therapy, occupational therapy, wound care and medical management. R1 discharged themselves from the SNF against medical advice and was admitted to Sweet Home Senior Living Facility with the plan of having home health. During R1’s stay at the SNF, R1 developed a pressure ulcer on their sacrum.

Interview conducted with the Licensee stated that the Licensee received a referral for R1 through a placement agency and the Licensee went to go visit R1 at the SNF to get more information regarding R1’s level of care on 01/25/2024. The Licensee said that the SNF nurse stated that R1 had a wound stage 3 or 4 but did not provide any documentation or paperwork to support the claim. The Licensee stated that R1 would be getting home health through Kaiser Permanente and wound care would be provided for R1. The Licensee believed at the time of R1’s admission to the facility that R1 had a stage 2 wound.

Per record review, R1’s ulcer is located on R1’s sacrum and is listed as unspecified in R1’s Kaiser Progress Notes (dated 01/19/2024) and Skilled Nursing Facility Discharge Summary (dated 01/24/2024). R1’s sacrum ulcer was noted as unstageable only in one document, Progress Notes dated 01/22/2024 from Kaiser. R1’s Progress Notes were not provided to the Licensee prior to admission. The documents that the Licensee obtained from the SNF include R1’s Admission Record, Interdisciplinary Discharge Summary and Kaiser Permanente Skilled Nursing Facility Discharge Instructions. None of the listed documents noted R1’s ulcer as unstageable. Although it was alleged that the Licensee was verbally told about R1’s unstageable ulcer, the SNF or Kaiser did not provide documentation to the Licensee that documented R1’s ulcer as unstageable nor did the Licensee obtained Kaiser documents.

Additionally, the LPA conducted an interview with R1’s Home Health on 2/22/2024. Interview revealed that R1’s wound improved and had no concerns regarding R1 care at the facility. Home health records did not list the stage of the ulcer.

Continued on LIC 9099-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240129144129

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SWEET HOME SENIOR LIVING FACILITY	FACILITY NUMBER: 197609845
	VISIT DATE: 07/11/2024

NARRATIVE

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The LPA did not have sufficient documentation to support the allegation. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

The LPA had several conversations with the Licensee regarding pressure injuries, healing wounds, and Restricted Health Conditions. The LPA educated the Licensee on the importance of not accepting residents with Stage 3, Stage 4 pressure injuries and unstageable wounds/ injuries unless with a hospice waiver and with resident receiving care for the pressure injury from a physician or an appropriately skilled professional. The LPA reminded the Licensee that she should be obtaining pertinent documents for all residents including hospital records. The LPA told the Licensee if a hospital or SNF verbally state that a resident has any kind of wounds or ulcers, that the Licensee needs to follow up appropriately and ensure that the resident is appropriate for the assisted living. The LPA also emphasized the importance of the Licensee obtaining home health and hospice plan of care and wound assessment documents to keep in resident’s file.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

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