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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610211
Report Date: 11/01/2023
Date Signed: 11/01/2023 11:04:09 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
07/28/2022 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20220728112027
FACILITY NAME:KITTRIDGE RCFEFACILITY NUMBER:
197610211
ADMINISTRATOR:MARTIR, FRANCISFACILITY TYPE:
740
ADDRESS:20702 KITTRIDGE STTELEPHONE:
(818) 854-6745
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 6DATE:
11/01/2023
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:James OlaoliaTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Due to inadequate supervision, resident suffered from a fall causing severe injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to deliver the findings regarding the above allegation. On July 28, 2022, Licensing received a report alleging potential neglect, as Resident 1 (R1) was present with a skull fracture, multiple bruises, and multiple scabs when admitted to the hospital. Furthermore, concerns were raised when the administrator was not forthcoming when asked about R1’s multiple falls. The 10 day visit was conducted by LPA Yelena Avetisyan on July 28, 2022. It was also referred and accepted as a full investigation by Investigation Branch (IB) Brian Static. IB investigation consisted of interviews and medical record review.

Per IB report, review of hospital records reveal R1 was admitted to the emergency room on 7/24/22. EMS observed R1 with bleeding from right ear and a hematoma on the scalp, sustained from a presumed unwitnessed fall. R1 underwent a CT scan, and a left sided subdural hematoma was found. Additionally, R1 was diagnosed with intercranial hemorrhage, right parietal temporal bone fracture, and subarachnoidal
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
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 4
Control Number 31-AS-20220728112027
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: KITTRIDGE RCFE
FACILITY NUMBER: 197610211
VISIT DATE: 11/01/2023
NARRATIVE
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hemorrhage. On 9/13/22 and 9/23/22, IB conducted interviews with R1’s responsible party, who confirmed that R1’s falls were unwitnessed and information from facility administrator regarding the falls were not forthcoming.

On 9/23/22, IB received additional information that R1 experienced another fall on 6/23/22, sustaining fractures at the left clavicle and left rib, displaced with no healing present.

On 10/20/22, IB conducted interviews with the facility administrator and staff, who confirmed that R1 was observed with blood coming from the ear on the morning of 7/24/22. They confirmed that R1 was transported to the hospital, where R1 was diagnosed with a skull fracture and subdural hematoma. Staff stated they did not witness R1’s fall or other traumatic events. Staff did admit to having trouble providing care for R1 due to R1’s progressing condition.

Although R1s falls were confirmed unwitnessed, the information that IB obtained reveal that R1 had a behavior that was progressing for the last few months. Furthermore, it was revealed that the facility did not implement sufficient fall preventive measures, after R1 experienced another significant injury from a fall prior, that happened on 6/23/22. The licensee was unable to provide the necessary care and supervision to meet R1’s needs. Therefore, based on the information obtained, the allegation of resident suffering fractures and injuries from falls due to inadequate care and supervision is Substantiated. Citations issued on the 9099D.

An Immediate Civil Penalties will be issued today, in the amount of $500.00. At this time, the administrator, Francis Martir is out on leave. LPA spoke with her back up administrator, Michael Custodio over the telephone and informed him that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).“Appeal Rights discussed. Exit interview held. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421IM (Civil Penalty Assessment), and Appeal Rights were provided to the house manager, James Olaolia who is present during this visit.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220728112027
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: KITTRIDGE RCFE
FACILITY NUMBER: 197610211
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2023
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange or assist in
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cont. and 07/24/22, R1 experienced unwitnessed falls sustaining significant injuries. The licensee did not provide the necessary care and supervision or care plan to meet R1’s increasing needs as preventive measures for these falls.
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arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: R1 was displaying wandering behaviors. Their mental condition was progressing. On 06/23/22 and
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As POC, licensee will provide training to address this section section of the regulation. As proof that POC was completed, licensee will submit proof of training and training log to the Licensing agency by November 8, 2023.
Type A
11/01/2023
Section Cited
CCR
87405(d)(1)
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Administrator – Qualifications and Duties: The administrator shall have the qualifications specified in Sections 87405(d)(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.This requirement was not met as evidenced by:
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As POC, the administrator will review this section of the regulation and self certify that they've read and understood this section of the regulation. As proof POC is completed, self certification is due to the Licensing agency by November 8, 2023.
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The administrator lacked the requisite knowledge and ability to provide R1 the assistance necessary to ensure their physical and mental health.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220728112027
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: KITTRIDGE RCFE
FACILITY NUMBER: 197610211
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2023
Section Cited
CCR
87211(a)(1)(B)
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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within
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nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by
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(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and
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R1 had a fall sustaining significant injuries on 6/23/22. A facility file review was conducted and the Licensee did not submit an Incident Report (LIC 624) to the licensing agency to report this fall. As POC, the licensee will conduct training to address this section of the regulation. POC due by 11/08/23
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4