197609871-11-19-2021-31-AS-CHAS-C9L2AZ-20211210161421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609871
Report Date: 11/19/2021
Date Signed: 11/19/2021 12:21:24 PM

Unsubstantiated

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
08/30/2021 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20210830153133

FACILITY NAME:	HEPZEBAH HOUSE		FACILITY NUMBER:	197609871
ADMINISTRATOR:	JACKSON, SYLVIA		FACILITY TYPE:	740
ADDRESS:	22230 VANOWEN ST		TELEPHONE:	(310) 213-4927
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91303
CAPACITY:	6	CENSUS: 4	DATE:	11/19/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Sylvia Jackson		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident sustained deep tissue pressure injury
Staff refused to seek medical attention for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with the administrator and explained the reason for this visit.
It is alleged that resident #1 (R1) sustained deep tissue pressure injury due to facility neglect. LPA conducted a previous visit on 8/31/21 where LPA conducted interviews with the administrator and obtained copies of pertinent information related to the complaint allegation. LPA also requested and received copies of R1’s hospice records which include R1’s treatment plan, visit notes, and wound treatment notes. Interviews on 8/31/21 revealed that R1 came into the facility on 3/19/21 under hospice care. A review of hospice records was conducted on 10/30/21. Records indicated that R1 first developed pressure injuries on 6/24/21. It was also noted on 6/24/21 that the pressure injuries that R1 developed would not be expected to heal due to R1’s co-morbidities.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

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-20210830153133

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: HEPZEBAH HOUSE	FACILITY NUMBER: 197609871
	VISIT DATE: 11/19/2021

NARRATIVE

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Over time, R1’s wounds worsened even though R1 was receiving wound treatment and visits from a hospice nurse several times a week between 6/24/21 and 8/22/21. Eventually on 8/22/21, R1 was placed on continuous hospice where they had a nurse with R1 twenty-four hours a day. The reason for R1 developing deep tissue injuries was not due to facility negligence. A review of hospice records and wound treatment notes did not indicate that facility staff were negligent in treating R1 while R1 was at the facility. This allegation is deemed unsubstantiated at this time.

Staff refused to seek medical attention for resident

It is alleged that R1's responsible person suggested that R1 be taken to the hospital due to their condition and the administrator refused to see medical attention for R1. LPA previously conducted interviews with R1's responsible person on 9/8/21 and with the facility administrator on 8/31/21. LPA also reviewed R1's hospice records on 10/30/21. Information obtained from interviews revealed that R1's responsible person did inquire with the administrator about R1 going to the hospital. Administrator explained that R1's condition was being treated under hospice care and that she would call R1's hospice nurse which she did do. A review of R1's hospice file revealed that R1 was being checked on several times a week between 6/24/21 through 8/22/21 due to their condition. Based on the information obtained through interviews and record review R1 was not refused medical attention therefore this allegation is deemed Unsubstantiated at this time.

Exit Interview conducted.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

LIC9099 (FAS) - (06/04)

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