197609871-3-11-2023-31-AS-NMAN-CPZRX3-20230317132403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609871
Report Date: 03/11/2023
Date Signed: 03/11/2023 10:44:30 AM

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
02/10/2022 and conducted by Evaluator Nicholas Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220210102557

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: 5	DATE:	03/11/2023
		UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Melende Andrada		TIME COMPLETED:	10:47 AM

ALLEGATION(S):

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Resident 1 (R1) was neglected while living at the facility

INVESTIGATION FINDINGS:

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This report is an addendum to the previous licensing report issued on 11/18/2022. After further review of available information, the final finding of the allegation was changed.

At 10:22 a.m. on 03/11/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with staff and disclosed the reason for the visit.

Regarding the allegation "Resident 1 (R1) was neglected while living at the facility", it was alleged that as a result of neglect, R1 was found unresponsive and was admitted to the hospital. LPA conducted an initial visit on 02/11/2022 at 10:10 a.m. and interviewed the administrator and conducted a facility record review. At 2:00 p.m. on 08/06/2022, LPA conducted a review of R1’s medical records obtained from Kaiser Permanente. On 09/19/2022 between 11:30 a.m. and 12:00pm, LPA conducted a follow-up interview with the Administrator and received photographic evidence regarding R1’s bruises and overall skin condition.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2023

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-20220210102557

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: 03/11/2023

NARRATIVE

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***This page was ammended to change findings from Substantiated to Needs Further Investigation. For final findings, see report delivered on 03/11/2023***

Information received revealed that R1 was admitted to the facility on 11/14/2020 upon discharge from the Kaiser Hospital. Upon arrival, R1 was covered in bruises all over their body. The Administrator took pictures of R1 bruises. The Administrator verified that they had knowledge of R1’s multiple health problems requiring close supervision. Further interviews revealed that R1 was retained in the facility between 11/14/2020 to 11/23/2020. Facility staff assisted R1 with incontinence care and never saw any redness or rashes on R1’s body. On 11/23/2020, staff attended to the resident and found R1 unresponsive. 911 was called and R1 was transferred to the hospital. A review of Hospital records revealed that R1 was admitted to the hospital on 11/12/2020 and discharged on 11/13/2020. R1 had multiple health problems requiring close supervision and frequent attendance. R1 was readmitted to the hospital on 11/23/2020 due to being unresponsive. The information revealed from medical records verified the information received from interviews. Overall interviews of facility staff and review of facility records does not reveal any relevant information to conclude that R1’s care and supervision was neglected at the facility. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

During complaint investigation LPA noted other Title 22 deficiencies unrelated to the complaint. The deficiencies were addressed during case management visits conducted on 02/11/2022 and 01/31/2023.

Exit interview was conducted and copy of report was issued.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2023

LIC9099 (FAS) - (06/04)

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