197609871-11-21-2024-31-AS-NGID-DBENYP-20241127095301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609871
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:32:34 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
05/01/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230501105604

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:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Eka Darsno, Staff		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility did not ensure that resident can attend a video visit with a physician.
Facility confiscated resident's personal item.
Staff engaged in verbal altercation in presence of resident
Resident doesn't have a call assistance button or a pendant

INVESTIGATION FINDINGS:

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At 10:00am, Licensing Program Analyst (LPA), Angela Panushkina, conducted a subsequent visit to deliver final report. LPA met with Staff #1 (S1), Eka Darsono, who granted access to the facility. Administrator was contacted and LPA explained the reason for the visit. Administrator was unable to come in and designated S1 to sign for the report.

During the initial visit conducted on 05/13/23, LPA requested resident and staff roster. At 10:05am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, relevant to the investigation. At approximately 10:10am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:30am – 12:10pm, LPA interviewed the Administrator, two (2) staff and five (5) out of five (5) residents.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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 31-AS-20230501105604

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: 11/21/2024

NARRATIVE

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Administrator informed LPA that R1’s visitor, who was not R1’s Power of Attorney (POA), would be very demanding and request S1 to provide detailed, daily information regarding R1’s food intake, care, etc. LPA was also informed that it was not fair to other residents that S1 was not available due to the "interrogation" process conducted by R1's visitor. So, the Administrator asked R1’s visitor, in a very professional tone of voice, to stop questioning facility staff and requesting extra work, since the facility staff is well aware of their duties and responsibilities. In addition, five (5) out of five (5) residents interviewed, expressed no concerns regarding this allegation. Therefore, based on interviews and LPA observation, this allegation is deemed Unsubstantiated at this time.

Allegation: Resident doesn't have a call assistance button or a pendant

It was alleged that the facility has no call assistance button/pendant for the resident. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that although the facility has call buttons available to provide to the residents, currently none of their residents required/requested to have call buttons/pendants. Moreover, LPA was informed that all residents are verbal and when called for an assistance, the staff can easily hear the resident, since all four (4) bedrooms are located so close to one another. Two (2) staff members interviewed corroborated the statement provided by the Administrator. LPA was also informed that R1 has a bell, however, R1 never used it for an assistance. Instead, R1 just verbally called for help/assistance. During the interview with R1, at 12:20pm, LPA asked R1 to call the staff for an assistance. LPA observed R1 verbally called for help and S1 immediately responded. Lastly, five (5) out of five (5) residents interviewed, expressed no concerns regarding this allegation. Therefore, based on interviews and LPA observation, this allegation is deemed Unsubstantiated at this time.

No deficiency cited during today's visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 31-AS-20230501105604

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: 11/21/2024

NARRATIVE

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Allegation: Facility did not ensure that resident can attend a video visit with a physician.

It was alleged that the facility did not provide residents (R1 in particular) with Wi-Fi to be able to have a virtual/zoom appointment with their Physician. To investigate this allegation, LPA conducted an interview with the Administrator and two (2) staff, who denied the above allegation. LPA was informed that the facility does have a Wi-Fi and Administrator provided the password. LPA was able to connect and use the facility Wi-Fi. Administrator also informed LPA that every time R1 is scheduled to see a doctor (in person or via zoom), the staff is willing to help/assist to get in, but R1 finds a reason to cancel and or reschedule. LPA conducted an interview with R1 who confirmed the statement provided by the Administrator. R1 also informed LPA that he/she didn’t feel well and canceled another appointment today (on 05/13/23) with the Dermatologist. Lastly, five (5) out of five (5) residents interviewed, expressed no concerns regarding this allegation. Based on interviews and LPA observation, this allegation is deemed Unsubstantiated at this time.

Allegation: Facility confiscated resident's personal item.

It was alleged that a package was delivered to the facility and a proof of delivery photo was available, however, the facility confiscated the order from R1. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that all packages/mail delivered for residents are always being distributed to their right owner. Moreover, interview with two (2) staff revealed that no package was delivered for R1 that was confiscated by the facility. In addition, interview with five (5) out of five (5) residents expressed no concern regarding this allegation. Lastly, LPA requested a photo proof of the package delivery at the door (from the witness) to be emailed/texted, but it was never provided. Therefore, based on interviews this allegation is deemed Unsubstantiated.

Allegation: Staff engaged in verbal altercation in presence of resident

It was alleged that the Administrator is yelling at residents and their visitors. To investigate this allegation, LPA conducted an interview with the Administrator and two (2) staff, and all parties interviewed denied the above allegation.
Continue on LIC9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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