197609893-4-18-2021-31-AS-NGID-C4EULT-20210628154116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609893
Report Date: 04/17/2021
Date Signed: 04/18/2021 09:19:44 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
12/10/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20201210132437

FACILITY NAME:	LAKEVIEW COMFORT LIVING INC		FACILITY NUMBER:	197609893
ADMINISTRATOR:	KESHISHIAN, TINA		FACILITY TYPE:	740
ADDRESS:	11406 KAMLOOPS STREET		TELEPHONE:	(818) 590-8557
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	6	CENSUS: 4	DATE:	04/17/2021
		UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Tina Keshishian - Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Uncleared staff providing care and supervision to residents

Facility is providing care for a resident with a prohibited health condition

Staff are mismanaging resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted a subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Tina Keshishian.

LPA conducted the initial visit on 12/18/2020, LPA conducted virtual physical plant tour, obtained relevant documents and interviewed the administrator. LPA also conducted interview with facility and Hospice agency staff. LPA also attempted multiple times to reach the reporting party to no avail. Regarding the allegation that uncleared staff is providing care and supervision to residents, LPA unannounced virtual visit to the facility on 12/18/2020 and 04/17/2021 revealed that Staff #1 (S1) and Staff #2 (S2) were working at the facility on both times. Licensing Information System (LIS) review also revealed that both S1 and S2 are both finger print cleared and associated at the facility. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2021

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-20201210132437

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: LAKEVIEW COMFORT LIVING INC	FACILITY NUMBER: 197609893
	VISIT DATE: 04/17/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that the facility is providing care for a resident with a prohibited health condition, LPA hospice medical record review on 04/17/21, revealed that resident #1 (R1) was admitted sometime in September 2020 with the Home health services. On December 2020, R1 was put on Hospice services who continued to attend to R1's medical condition including gastronomy tube (g-tube). LPA interview with Hospice nurse on 04/17/21 confirmed that the Hospice Agency took care of R1's g-tube care, maintenance and feeding on a daily visit basis. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Regarding the allegation that staff are mismanaging resident's medication, LPA hospice and facility medication record review on 04/17/21 revealed that two (2) of the residents on hospice services had a PRN or as needed prescription for morphine. Facility PRN log review however, revealed that none of these medication was administered to residents while in care. LPA interview with current staff on 04/17/2021 confirmed that none of the staff have provided or administer any morphine to any of these two (2) residents on hospice services.

Exit interview conducted. Copy of this report issued via email for signature.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2021

LIC9099 (FAS) - (06/04)

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