197610154-7-11-2024-31-AS-EMIR-D7JQJJ-20240726121249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610154
Report Date: 04/25/2024
Date Signed: 07/11/2024 01:49:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
04/06/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230406143049

FACILITY NAME:	A PRECIOUS CARE VILLA		FACILITY NUMBER:	197610154
ADMINISTRATOR:	DOMINGO, OLIVER		FACILITY TYPE:	740
ADDRESS:	8413 RHEA AVE		TELEPHONE:	(818) 626-9343
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 5	DATE:	04/25/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	DOMINGO, OLIVER - Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff authorized Hospice care for resident without resident's consent.

INVESTIGATION FINDINGS:

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This is an amended report of the prior investigation report delivered on 04/06/24. Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced visit to this facility. LPA met with Administrator Oliver Domingo and explained the reason for the visit.

LPA conducted a physical plant tour, to ensure the health and safety of the residents are protected and the physical plant is in compliance with Title 22 Regulations. Based on information obtained and the appeal granted to the licenseee on June 26, 2024, the allegation that Staff authorized Hospice care for the resident without the resident's consent is deemed Unsubstantiated.

Exit interview conducted and copy of this report delivered.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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 3

Control Number 31-AS-20230406143049

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A PRECIOUS CARE VILLA	FACILITY NUMBER: 197610154
	VISIT DATE: 04/25/2024

NARRATIVE

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Interview with Reporting Party(RP) revealed that R1 was discharged from the hospital on or around 04/01/23 without hospice order from the doctor. Interview with Assistant Administrator revealed that R1's day of Admission at the facility was on 04/01/23 with Hospice order already initiated by a referral agency. According to R1's doctor notes R1 was not placed on hospice care at discharge. However, it has been initiated and approved by the Assistant Administrator of the facility for R1 to receive hospice care.

Based on information obtained, interviews and record reviews, the allegation deemed Substantiated at this time.

Exit interview conducted, citations issued, appeal rights given and copy of this report delivered.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230406143049

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A PRECIOUS CARE VILLA	FACILITY NUMBER: 197610154
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 04/25/2024 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	Conduct inimical- (3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not evidenced by:	1 2 3 4 5 6 7	Within 24 hours, the Administrator and Administrator Assistant will submit a plan to address this section of the health and safety code. The plan must inlcude the vendor number, training topic and attendance log. Training and certification must be submitted to the licensing agency by May 9, 2024.
	8 9 10 11 12 13 14	Based on interviews and information obtained it was confirmed that R1 was placed on hospice care without authorization from their primary physician, nor their consent. This poses an immediate risk to the residents in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type A 04/26/2024 Section Cited CCR 87468.1(a)(16)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)(16) To receive or reject medical care or other services. This requirement is not evidenced by:	1 2 3 4 5 6 7	Within 24 hours, the Administrator and Administrator Assistant will submit a plan to address this section of the regulations. The plan must inlcude the vendor number, training topic and attendance log. Training and certification must be submitted to the licensing agency by May 9, 2024.
	8 9 10 11 12 13 14	Based on information obtained R1 was not able to accept or reject hospice care. This poses an immediate risk to the residents in care.	8 9 10 11 12 13 14

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: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

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