197610178-6-27-2023-31-AS-EMIR-CUWUV4-20230821155431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610178
Report Date: 06/27/2023
Date Signed: 06/27/2023 04:30:43 PM

Substantiated

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
06/19/2023 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20230619091039

FACILITY NAME:	ANNIKA GRACE CARE HOME		FACILITY NUMBER:	197610178
ADMINISTRATOR:	BATUIAN, JOZAM LATAYAN		FACILITY TYPE:	740
ADDRESS:	6338 W AVENUE J11		TELEPHONE:	(818) 802-8004
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 2	DATE:	06/27/2023
		UNANNOUNCED	TIME BEGAN:	11:47 AM
MET WITH:	Jozam Batulan		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility admitted or retained a resident with stage 3 pressure injury.

INVESTIGATION FINDINGS:

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On 06/27/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit for the above allegation. LPA arrived at the facility at 11:47 a.m. and was greeted by the administrator Jozam Batulan. LPA explained to Administrator the purpose of the visit. Entrance interview conducted.

At 12:00 p.m. LPA and administrator Jozam conducted a physical plant tour to ensure the health and safety of the residents in care. No issues or concerns were observed. From 12:15 p.m. to 2:40 p.m. LPA reviewed resident records and obtained documents relevant to this investigation. From 2:41 p.m. to 3:30 p.m. LPA interviewed credible witnesses.

Allegation: Facility admitted or retained a resident with stage 3 pressure injury.
It is alleged facility admitted a resident#1(R1) with a Stage 3 pressure injury and (R1) has been receiving wound care by a home health agency at the facility.
(LIC9099-C Continued on to next page)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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-20230619091039

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: ANNIKA GRACE CARE HOME	FACILITY NUMBER: 197610178
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/29/2023 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615(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 is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will abide by state licensing regulations, and will not retain any resident with a prohibited health condition. Licensee will communicate with Home Health and R1's family about regulation cited and will certify the regulation has been understood and complied with.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee failed to ensure above regulation by retaining R1 with a stage 3 pressure injury, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Licensee will submit to LPA arrangements made for R1 so that facility may be in compliance with regulation by the POC due date.
	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: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230619091039

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: ANNIKA GRACE CARE HOME	FACILITY NUMBER: 197610178
	VISIT DATE: 06/27/2023

NARRATIVE

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(LIC9099-C Continued)
Interview with the administrator revealed R1 was admitted to the facility with a pressure injury and R1 was being provide wound care by two home heath agency prior to admittance to facility and currently. Records revealed home health agency has been providing assistance with wound care from April 2023 and currently. Two credible witnesses corroborate R1 was or is receiving wound care for a Stage 3 pressure injury. Based on record review and interviews, the allegation mentioned is Substantiated at this time.

Deficiencies issued per CA Code of Regulations, Title 22 (refer to LIC9099-D). Report signed and delivered. Appeal Rights provided. Exit interview conducted.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC9099 (FAS) - (06/04)

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