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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610017
Report Date: 03/25/2022
Date Signed: 03/25/2022 11:05:27 AM

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
05/07/2021 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20210507185145
FACILITY NAME:SHERWOOD FOREST SENIOR LIVINGFACILITY NUMBER:
197610017
ADMINISTRATOR:MKRTCHYAN, ANIFACILITY TYPE:
740
ADDRESS:8635 AMESTOY AVENUETELEPHONE:
(818) 322-2222
CITY:SHERWOOD FORESTSTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 4DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gohar AkashyanTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident has multiple stage III and IV pressure injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent visit to facility to deliver the findings for the above allegation. The 10 day visit was initiated by LPAs Yelena Avetisyan and Wendell Smith. Complaint was then referred to Investigations Branch (IB) investigator Dennis Seng. IB’s investigation consisted of facility file review, obtaining and reviewing medical records, interviewing facility staff, witnesses, and clients.

IB’s investigation revealed as follows:
R1 suffered multiple pressure injuries to the body due to neglect and lack of supervision. R1 was admitted in May 2021 with a history of pressure injuries. Medical records and interviews with wound specialists confirm that R1 had stage three and stage four pressure injuries to the coccyx and sacrum that were not healing or improving. Licensee placed the responsibility of scheduling R1’s wound care
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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 31-AS-20210507185145
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: SHERWOOD FOREST SENIOR LIVING
FACILITY NUMBER: 197610017
VISIT DATE: 03/25/2022
NARRATIVE
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treatment solely to their family, causing R1’s condition to worsened. Licensee failed to assist R1’s family with finding alternative placement options when they were aware of the condition worsening.

Based on interviews conducted and record review, there is enough evidence to corroborate the allegation of R1 sustaining multiple pressure injuries due to neglect. Therefore, the allegation is Substantiated. Citation issued on the 9099D and an immediate civil penalty of $500 warranted.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20210507185145
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: SHERWOOD FOREST SENIOR LIVING
FACILITY NUMBER: 197610017
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/25/2022
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist
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An immediate civil penalty of $500 assessed. As POC, licensee will obtain training to address this section of the regulation. Proof of the training is due to CCL no later than 04/08/22.
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in arranging, for medical and dental care appropriate to the condition and needs of the resident: This requirement has not been met as evidenced by: Medical records and interveiws with wound care specialist confirming R1 had stage 3 and 4 pressure wounds were not improving. Licensee placed the responsibility of scheduling R1's wound care treatment solely to their family, causing R1's condition to worsened. Licensee failed to assist R1's familiy with finding alternative placement options when they were aware of their conditions worsening.
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Administrator will be appealing the decision.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3