197610174-1-31-2023-31-AS-NMAN-CPVRAG-20230313125107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610174
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:39:19 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
11/28/2022 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20221128163727

FACILITY NAME:	RIDGEVIEW HOME CARE CENTER		FACILITY NUMBER:	197610174
ADMINISTRATOR:	MANICDAO, MARY PRINCESS F.		FACILITY TYPE:	740
ADDRESS:	2327 RIDGEVIEW AVE		TELEPHONE:	(323) 308-8002
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90041
CAPACITY:	6	CENSUS: 4	DATE:	01/31/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Mary Princess F. Manicado		TIME COMPLETED:	09:46 AM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegation. LPA met with the administrator, Mary Princess F. Manicdao, and explained the reason for the visit.

--- Resident sustained multiple pressure injuries while in care.

It was alleged that, due to neglect, Resident #1 (R1) sustained pressure injuries which appear severe. To investigate the allegation, on 11/29/2022, LPA requested documents at 11:30am and interviewed two (02) staff from 11:45am - 01:00pm. Record reviews from Home Health indicate that R1 has multiple stage three (03), stage four (04) and unstageable pressure injuries/wounds.

(Cont. on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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-20221128163727

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: RIDGEVIEW HOME CARE CENTER	FACILITY NUMBER: 197610174
	VISIT DATE: 01/31/2023

NARRATIVE

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During interviews, Staff #1 (S1) and Staff #2 (S2) stated that R1 was admitted with multiple wounds and admitted that, while in care, R1 developed an unstageable wound on the left hip that became dark and dry on the surface with a malodorous discharge. Based on record reviews and interviews, the allegation is substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Immediate $500.00 penalty was issued due to the neglect of R1's medical care which resulted in an immediate health and safety hazard to the resident.

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20221128163727

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: RIDGEVIEW HOME CARE CENTER	FACILITY NUMBER: 197610174
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/01/2023 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	Prohibited Health Conditions - (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced	1 2 3 4 5 6 7	Licensee shall submit a written plan describing how the facility shall prevent injuries to residents as a result of any deficiencies incurred by the facility. Licensee shall submit to CCL no later than 02/01/2023. An immediate penalty of $500 shall be assessed as a result of the severe injury to R1.
	8 9 10 11 12 13 14	by; Based on record reviews & interviews, R1 was admitted with stage 3 & 4 pressure injuries and developed unstageable wounds while in care which poses an immediate health and safety risk to residents in care. An immediate penalty of $500 shall be assessed as a result of the severe injury to R1.	8 9 10 11 12 13 14
Type A 02/01/2023 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	Basic Services. (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs…., either directly or through outside resources.	1 2 3 4 5 6 7	By the POC due date, the Licensee shall submit a written plan describing how the facility shall prevent admitting and/or retaining the residents with prohibited health condition. Licensee shall submit to CCL no later than 02/01/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by. Licensee did not ensure to provide required medical care to R1 requiring a higher level of care which poses an immediate health and safety risk to 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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

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