197610098-7-8-2024-31-AS-TAGD-D77P53-20240715110006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610098
Report Date: 07/08/2024
Date Signed: 07/08/2024 10:52:31 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
10/13/2022 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20221013141941

FACILITY NAME:	AFFORDABLE BOARD AND CARE INC.		FACILITY NUMBER:	197610098
ADMINISTRATOR:	KESHISHI, VILBERT		FACILITY TYPE:	740
ADDRESS:	11382 KAMLOOPS ST		TELEPHONE:	(818) 397-5690
CITY:	LAKEVIEW TERRACE	STATE: CA	ZIP CODE:	91342
CAPACITY:	6	CENSUS: 6	DATE:	07/08/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Vilbert Keshishi		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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1. Staff does not ensure that resident receive adequate wound care
2. Staff left resident soiled in feces
3. Staff are severely restricting residents’ visitation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Vilbert Keshishi, and informed him the purpose of the visit, which is to finalize the above complaint allegations. On October 13, 2022, the Woodland Hills Regional South Adult and Senior Care Office, received a complaint, for the allegations mentioned above. On August 31, 2021, the complaint was referred to the Community Care Licensing Division’s (CCLD’s) Investigations Branch (IB), and assigned to Investigator Jose Santana, to investigate and determine the finding for allegation # 1. LPA Tuesday Cabiness, conducted a subsequent visit, interviewed staff and residents, pertaining to allegation # 2 and 3. The following was determined:

Allegation # 1: “Staff does not ensure that resident receive adequate wound care”. On October 14, 2022, from 930am to 12pm, former LPA Wendell Smith, conducted the initial complaint visit, as well as conducted a physical plant inspection, reviewed, and obtained resident medical records, and interviewed staff. Investigator Santana conducted interviews, obtained, and reviewed facility documents and medical records, pertaining to allegation #1 on various dates, from approximately October 2022 through November 2022. The following is a

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

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-20221013141941

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AFFORDABLE BOARD AND CARE INC.	FACILITY NUMBER: 197610098
	VISIT DATE: 07/08/2024

NARRATIVE

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summary of the IB investigation and it’s finding of the allegation. Resident #1 (R1) was admitted to the facility on 09/26/2022 and already being regularly treated by hospice nurses and wound care physicians prior to being admitted. Once the facility retained R1, the wound care services continued for R1’s wound, and the Administrator, including staff, treated the wound in between skilled nurses’ visits and per hospice care instructions. Investigator Santana reported that the complainant was under the impression (R1) developed the wound while in the care of the facility, and that the facility was not allowed to retain or admit (R1) with the wound. Further information by Investigator Santana revealed, the facility met the necessary requirements to retain and treat R1, therefore, based on the investigation conducted by IB investigator Santana, and all information obtained, through interviews and documentation, the allegation is deemed UNSUBSTANTIATED at this time.

Allegation # 2: “Staff left resident soiled in feces”. On October 14, 2022, from 930am to 12pm, former LPA Wendell Smith, conducted the initial complaint visit, as well as conducted a physical plant inspection, reviewed, and obtained resident medical records, and interviewed staff. LPA T. Cabiness reviewed facility documents, resident and medical records, and other documentation pertaining to allegation # 2 on various dates and times, in October 2022, December 2022, July 2023, and December 2023, and May 2024. On 05/24/2024, LPA T. Cabiness conducted a subsequent visit and interviewed staff, as well as obtained additional documentation. From the information obtained, resident # 1 (R1) was diagnosed a severe medical condition that caused diarrhea. It was reported to LPA that staff had to change R1’s diarrhea several times throughout the day. On the day in question, pertaining to the allegation, although it was reported, R1’s diaper was soiled with feces, it was due to R1’s medical condition, and not by the negligence of staff. Therefore, based on interviews, and documentation, there is insufficient evidence to prove the allegation, and it’s Unsubstantiated at this time.

Allegation # 3: “Staff are severely restricting residents’ visitation”. On October 14, 2022, from 930am to 12pm, former LPA Wendell Smith, conducted the initial complaint visit, as well as conducted a physical plant inspection, reviewed, and obtained resident medical records, and interviewed staff. LPA T. Cabiness reviewed facility documents, resident and medical records, and other documentation pertaining to allegation # 3, on various dates and times, in October 2022, December 2022, July 2023, and December 2023, and May 2024. On 05/24/2024, LPA T. Cabiness conducted a subsequent visit and interviewed staff, as well as

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20221013141941

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AFFORDABLE BOARD AND CARE INC.	FACILITY NUMBER: 197610098
	VISIT DATE: 07/08/2024

NARRATIVE

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obtained additional documentation. From the information obtained, R1 was scheduled for a home health nurse to visit and provide services. On the day in question, (2) home health nurses showed up to the facility at the same time. There was a schedule conflict and the Administrator requested (1) nurse to provide the services for R1. Therefore, based on interviews, the allegation is Unsubstantiated at this time.

Exit interview and copy of report provided to Administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC9099 (FAS) - (06/04)

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