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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609986
Report Date: 04/14/2021
Date Signed: 04/14/2021 06:13:36 PM



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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2020 and conducted by Evaluator Aja Richardson
COMPLAINT CONTROL NUMBER: 29-AS-20200917154753
FACILITY NAME:ARBOR GROVE CAREFACILITY NUMBER:
197609986
ADMINISTRATOR:DOLMAN, ANDREWFACILITY TYPE:
740
ADDRESS:14819 VALERIO STREETTELEPHONE:
(818) 809-2594
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 5DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Andrew Dolman, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident developed multiple pressure injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Aja Richardson conducted an unannounced visit to deliver the findings on the above allegation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint visit was conducted telephonically with, the facility administrator.

On 9/18/2020, the Woodland Hills North Adult and Senior Care Regional Office received a complaint regarding Resident #1 (R1) developing multiple pressure injuries while in the care of facility staff, which were not reported to R1’s physician or any other medical professional. To investigate the allegation, on 09/18/2020, the Woodland Hills North Adult and Senior Care Regional Office referred this case to the Departments Investigations Branch (IB). On 9/20/20, IB accepted the assignment as a full investigation and Investigator Johnny Canto was assigned to the case.
Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20200917154753
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARBOR GROVE CARE
FACILITY NUMBER: 197609986
VISIT DATE: 04/14/2021
NARRATIVE
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On 11/25/2020, interviews with the Administrator, Facility Staff, and R1 were conducted by Investigator Canto between 11:30 a.m. and 12:00 p.m. On 10/2/2020 at 10:15 a.m., the hospital social worker was interviewed; and, on 10/5/2020 hospital records were reviewed.

According to the investigation, on 8/20/2020, facility staff called R1's physician to notify them of R1’s agitation and inability to sleep. Interviews with the facility staff and the Administrator confirmed that on 8/20/2020, they failed to mention to the physician that resident #1 (R1) had developed pressure injuries. On 9/3/2020, a nurse came to assess R1 due to a home health referral on 9/2/2021. During the assessment, R1 was noted to have a Stage 3 pressure injury to sacral area, with measurements of 1.5 cm x 2 cm x 0.3 cm; an unstageable area on the right heel, with measures of 2 cm x 1.4 cm x 0.6 cm; and, an unstageable area on the left heel with measurements of 2.3 cm x 1.6 cm x 0.4 cm. According to R1’s medical records, R1 was under home health care for pressure injuries from 9/3/2020 to 9/8/2020, until being admitted to the hospital. The home health agency put in a referral for R1 to be hospitalized once the nurse understood that Departmental regulations would not allow for R1 to reside at facility with pressure injuries above a stage 2 without an approved exception by the Department. As a result, R1 was transferred to the hospital on 9/8/2021. In addition, according to interviews conducted, the licensee was unaware that they were unable to retain a resident with a Stage 3 pressure injury without an approved exception by the Department. Due to R1 residing in facility with multiple pressure injuries and facility staff failing to disclose and seek medical attention for R1’s pressure injuries, this allegation is Substantiated.



The following deficiency is observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. An immediate $500 civil penalty assessed. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. A copy of the report was provided via email for signature, along with the appeal rights.

Report emailed to Administrator for signature.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20200917154753
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARBOR GROVE CARE
FACILITY NUMBER: 197609986
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2021
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Conditions. 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: (1) stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:

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The Administrator has agreed to do the following:
1. Administrator will review Regulation 87615 regarding Prohibited Health Conditions. A Statement of Understanding will be submitted by 4/15/2021
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Based on the investigation, record review and interview, licensee did not comply with the above section due to R1 sustaining unstageable pressure injury, yet R1 was not under the care of hospice services for wound care, which poses an immediate health and safety risk to R1.
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2. Care staff wlill review Regulation 87615(a)(1); Administrator will inform CCLD when this is completed no later than 04/15/21

Immediate civil penalty of $500 was also assessed.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
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