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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610101
Report Date: 08/12/2022
Date Signed: 08/12/2022 12:13:13 PM

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
02/01/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220201103420
FACILITY NAME:HAMLIN ELDER CAREFACILITY NUMBER:
197610101
ADMINISTRATOR:BIGORNIA, LIMA ROSEFACILITY TYPE:
740
ADDRESS:20300 HAMLIN ST.TELEPHONE:
(818) 912-6289
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: DATE:
08/12/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lima Rose BigorniaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staffs' neglect led to resident developing pressure injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with the administrator and explained the reason for this visit.
It is alleged that due to facility staff neglect resident #1 (R1) and R2 developed pressure injuries. Previous visits were conducted on 2/3/22 and 8/3/22. Interviews were previously conducted with the administrator and R2's responsible person. During today's visit LPA reviewed R1 and R2's facility file which included home health notes for R1 from 9:30-11:30am. Information obtained from interviews revealed that R2 did not have any wounds according to R2's family. Record review and interviews reveal that R1 did have a wound on their back but that Care Connection Home Health Agency came daily to attend to the wound. A review of the home health records did not indicate that R1 developed any new wounds while in care. R1 was admitted back to the facility on 12/30/21 after spending a month in the hospital. When R1 was admitted back to the facility they came back with a wound on their back which was noted by the administrator. As of 12/30/21 when R1 was admitted back to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
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 2
Control Number 31-AS-20220201103420
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: HAMLIN ELDER CARE
FACILITY NUMBER: 197610101
VISIT DATE: 08/12/2022
NARRATIVE
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with home health services. On 2/11/22 R1 was put on hospice to start receiving hospice services. Based on the information obtained through interviews, facility file review, and home health record review this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2