197609928-4-4-2022-31-AS-CHAS-CH8PMU-20220812112651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609928
Report Date: 04/04/2022
Date Signed: 04/04/2022 12:44:30 PM

Substantiated

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
03/10/2022 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20220310114605

FACILITY NAME:	COVELLO TOP NOTCH CARE LLC		FACILITY NUMBER:	197609928
ADMINISTRATOR:	LOPEZ, DAVID		FACILITY TYPE:	740
ADDRESS:	18807 COVELLO STREET		TELEPHONE:	(818) 855-9615
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 4	DATE:	04/04/2022
		UNANNOUNCED	TIME BEGAN:	11:16 AM
MET WITH:	David Lopez		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Facility retained a resident with prohibited health condition.
Uncleared staff providing care and supervision to residents.

INVESTIGATION FINDINGS:

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At 11:15 AM on 04/04/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted a subsequent complaint visit. LPA met with Administrator and disclosed the reason for the visit.

Facility retained a resident with prohibited health condition.

Regarding the allegation above, it was alleged the facility retained a resident with a Gastronomy tube (G-tube) without an exception or hospice agreement. LPA interviewed Administrator at approximately 1:45 p.m. on 03/14/2022. Administrator confirmed Resident #1 (R1) was admitted to the facility on hospice with a G-tube. R1 later withdrew from their hospice agreement. Administrator stated R1 used home health services after being discharged from hospice. LPA reviewed facility files at approximately 1:50 p.m. on 03/14/2022 and 11:20 a.m. on 04/04/2022. R1 entered a hospice agreement from 07/05/2021 to 03/02/2022. R1 entered a new hospice agreement on 03/19/2022. From 03/02/2022 to 03/19/2022, R1 was retained at the facility with a prohibited health condition.

Substantiated

Estimated Days of Completion: 20

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

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-20220310114605

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: COVELLO TOP NOTCH CARE LLC	FACILITY NUMBER: 197609928
	VISIT DATE: 04/04/2022

NARRATIVE

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R1 did not have an approved exception during that period. Based on interview and file review, the above allegation is deemed substantiated at this time.

Uncleared staff providing care and supervision to residents.

Regarding the allegation above, it was alleged staff members provided care without criminal background clearances. LPA interviewed Administrator at approximately 1:45 p.m. on 03/14/2022 and at 11:25 a.m. on 04/04/2022. Administrator confirmed 4 out of 7 staff members had not been associated to the facility or submitted criminal background checks. LPA conducted a record review on the Licensing Information System (LIS) on 03/14/2022 at approximately 8:00 a.m. LPA and Administrator reviewed an LIS document and confirmed 4 out of 7 staff members were not associated to the facility. Based on interview and record review, the above allegation is deemed substantiated at this time.

Deficiencies noted on 9099-D page.

Exit interview conducted. Copy of report and appeal rights issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20220310114605

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: COVELLO TOP NOTCH CARE LLC	FACILITY NUMBER: 197609928
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/04/2022 Section Cited CCR 87615(a)(2)	1 2 3 4 5 6 7	87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Resident entered a new hospice agreement on 03/19/2022. Licensee will require a month notice from hospice agencies for any upcoming changes to resident care plans. Upon discharge, Licensee will notify POA and LPA of changes. Licensee will review California Code of Regulations Title 22 sections 87633 and
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not request an exception for R1's prohibited health condition after they were discharged from hospice. This poses a potential Health, Safety, and Personal Rights risk to residents in care.	8 9 10 11 12 13 14	87616 and submit proof of training to LPA by POC due date.
Type A 05/04/2022 Section Cited HSC 1569.17(b)(1)(D)	1 2 3 4 5 6 7	§1569.17 Fingerprints and criminal records (b) In addition to the applicant, the provisions of this section shall apply to criminal record clearances and exemptions for the following persons: (1)(D) Any staff person, volunteer, or employee who has contact with the clients. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee submitted criminal background clearances and transfer requests of S1, S2, S3, and S4 on 03/16/2022 at the Woodland Hill Regional Office. Licensee will review California Code of Regulations Title 22 section 87355 and submit proof of training to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not obtain criminal background clearances or transfers for 4 out of 7 staff which poses a potential Health, Safety, and Personal Rights risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

LIC9099 (FAS) - (06/04)

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