197610151-2-29-2024-31-AS-EMIR-DBZUGV-20241216143454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610151
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:23:59 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
02/28/2024 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20240228094940

FACILITY NAME:	AEGIS LIVING GRANADA HILLS		FACILITY NUMBER:	197610151
ADMINISTRATOR:	MATTHEW LA VINE		FACILITY TYPE:	740
ADDRESS:	10801 LINDLEY AVE		TELEPHONE:	(818) 363-3373
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	100	CENSUS: 76	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Matthew La Vine		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff restrained resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Ray Comer and Michael Cava conducted a complaint visit to the facility to investigate the above allegation. It was reported that facility staff had “sandwiched" Resident 1 (R1) between a wall and the table intentionally to keep them from falling over. This was observed several times during facility visits. Photos were obtained prior to investigation. LPAs met with the administrator, Matthew La Vine, and advised him of the complaint. Todays investigations consisted of interviews with staff, record review, and a physical plant inspection.

Although, during the day's investigation, both LPAs Comer and Cava did not observe R1 "sandwiched" between the wall and table, the LPA interviews with staff confirm that caregivers would bring the table close to R1 to assist in feeding and restrict movement to minimize R1 from pushing their wheelchair over.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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 5

Control Number 31-AS-20240228094940

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: AEGIS LIVING GRANADA HILLS	FACILITY NUMBER: 197610151
	VISIT DATE: 02/29/2024

NARRATIVE

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Pursuant to title 22, division 6, chapter 8, "Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. Therefore, based on the information obtained, the allegation of resident being restrained is Substantiated. Citation issued on the 9099D. Copy of this report and appeal rights given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20240228094940

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: AEGIS LIVING GRANADA HILLS	FACILITY NUMBER: 197610151
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/29/2024 Section Cited CCR 87608(a)(1)	1 2 3 4 5 6 7	Postural Support: Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not	1 2 3 4 5 6 7	As POC, the administrator will hold staff training to address this section of the regulation. As proof training was held, administrator will submit a copy of the training log and staff sign in sheet to the licensing agency by March 7, 2024
	8 9 10 11 12 13 14	limited to, preventing a resident from falling out of bed, a chair, etc. This requirement was not met as evidenced by: Staff admission during interviews.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
02/28/2024 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20240228094940

FACILITY NAME:	AEGIS LIVING GRANADA HILLS		FACILITY NUMBER:	197610151
ADMINISTRATOR:	MATTHEW LA VINE		FACILITY TYPE:	740
ADDRESS:	10801 LINDLEY AVE		TELEPHONE:	(818) 363-3373
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	100	CENSUS: 76	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Matthew La Vine		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Neglect by facility staff resulted in injury to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Ray Comer and Michael Cava conducted a complaint visit to the facility to investigate the above allegation. On or around 01/12/24, it was reported that staff neglect attributed to injuries to Resident 1 (R1) foot and ankels. R1 requires the use of a wheelchair, since they can no longer ambulate. LPAs met with the administrator, Matthew La Vine, and advised him of the complaint. Todays investigations consisted of interviews with staff, record review, and a physical plant inspection.

Interviews with staff and record review revealed that on 01/12/24, R1 was noted to have a change in condition. R1's left foot and ankle became swollen, due to edema. In addition to the swelling, R1's toenail apeared overgrown and bending backwards. Nurse was called in for the treatment. R1's family was notified. R1 was not in pain or discomfort. Based on the information obtained, ther was insufficient evidence to prove that staff neglected R1, causing injury. Therefore the allegation is deemed Unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5