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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610244
Report Date: 11/22/2024
Date Signed: 11/22/2024 11:45:15 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
05/21/2024 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20240521090631
FACILITY NAME:PEACEFUL KINGDOM HOME CARE IFACILITY NUMBER:
197610244
ADMINISTRATOR:PAREDES, VICTORIAFACILITY TYPE:
740
ADDRESS:17740 BALTAR ST.TELEPHONE:
(818) 339-3867
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 5DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jose Hernandez, AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff neglect led to resident sustaining pressure injuries
INVESTIGATION FINDINGS:
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At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with Administrator and explained the reason for the visit.
On 05/21/2024, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation, “Staff neglect led to resident sustaining pressure injuries.” The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to investigators Jasmin Mendez-Chavez and Philippe Ryan Miles.
On 05/22/2024 LPA Rahimi conducted an initial 24-hour complaint visit. At 09:45 AM, LPA conducted tour of the facility. At 09:55 AM, LPA obtained copies of pertinent documentation which included but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan.
Investigator Mendez-Chaves conducted interviews with witnesses on 06/20/2024 and 06-25-2024, and facility staff on 07/10/2024 and 09-04-2024. Hospital Medical records were subpoenaed for multiple facilities 06/05/2024, 06/20/2024 and 07/01/2024.
Continue on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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 6
Control Number 31-AS-20240521090631
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEACEFUL KINGDOM HOME CARE I
FACILITY NUMBER: 197610244
VISIT DATE: 11/22/2024
NARRATIVE
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The investigation findings revealed that R1 had been living at this facility since April 07, 2024. Upon R1’s admission to the facility, R1 was noted to have stage 2 pressure injuries near the buttocks in which both staff and the administrator acknowledge. Because of this condition, R1’s responsible party admitted R1 to A1 Palliative and Hospice on 04/09/2024. Approximately mid-April 2024, the LVN from A1 Hospice agency ordered wound specialist for R1 who visited R1 only once at the facility. Although interview with a witness revealed that A1 Palliative and Hospice Care were responsible for providing wound care to R1; and due to staff shortage the agency was unable to provide sufficient wound care to R1, it was facility’s responsibility to contact the resident primary care doctor for alternative medical attention.

On 05/12/2024, due to a medical emergency, R1 was admitted to Northridge Hospital where it was discovered that R1 had developed stage 3 through unstageable pressure wounds. Prior to re-admitting R1 back to the facility on 05/15/2024, facility staff failed to do a reassessment for R1. Therefore, the Administrator failed to get R1 on proper medical attention or assist with obtaining a wound specialist to address these issues. Subsequently on 05/19/2024, R1 was re-admitted to the hospital and review of hospital records revealed that R1 beside having stage 3/unstageable pressure wound injuries she/he developed maggots in their wounds. Based on the interviews conducted and supporting documents provided regarding R1’s pressure injuries, the facility retained R1 knowing his/her pressure injuries were worsening and failed to seek medical attention in a timely manner. There is sufficient evidence to support the allegation of Neglect/Lack of Care and Supervision; there for the finding(s) are substantiated.


Continue on LIC 9099C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20240521090631
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEACEFUL KINGDOM HOME CARE I
FACILITY NUMBER: 197610244
VISIT DATE: 11/22/2024
NARRATIVE
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The licensee was informed that a civil penalty maybe be assessed based on Health and Safety Code 1569.49(f).
Deficiencies and Civil penalties were issued per CA code of Regulations Title 22 or Health and Safety Code.
See 9099D's included with this report.
Appeal rights issued.
Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20240521090631
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEACEFUL KINGDOM HOME CARE I
FACILITY NUMBER: 197610244
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall ... (1) The licensee shall... for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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The Administrator has agreed to the following: All staff take state approved training on the regulation Incidental Medical and Dental
Services and recognizing the signs of developing pressure injuries. Submit training schedule with the vendors name, date of schedule.
This is a zero tolerance and an immediate civil penalty of $500.00 will be assessed.
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Based on interview and record reviews, licensee did not comply with the section cited above by providing care to R1 without hiring a Wound Specialist and or a medical professional from 04/07/2024 to 05/19/24, which poses/posed an immediate health and safety risk to resident in care.
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Type A
11/25/2024
Section Cited
CCR
87411(a)
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87411 (a) Personnel Requirements – General (a) Facility personnel shall at all times be ... competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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The Administrator has agreed to the following:
All staff take state approved training on the regulation Personnel Requirement. Submit training schedule with the vendors name, date of schedule. Submit a complete the body check forms for each resident for the next two week.
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The communication form shall become an addendum to the plan of operation. Based on staff interviews and review of medical records facility staff lack the knowledge to recognize signs of illness which require medical attention. This is an immediate health and safety risk to the residents in care.
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Submit a blank form and cover sheet to indicate addendum. Upon completion submit the training material and staff sign in sheet. Submit a communication form in which staff do daily body checks. As of completion of the training
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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20240521090631
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEACEFUL KINGDOM HOME CARE I
FACILITY NUMBER: 197610244
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2024
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not....shall not be admitted or retained in a residential ...for the elderly: (1) Stage 3 pressure injuries.
This requirement is not met as evidenced by:
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The Administrator has agreed to the following:
All staff take state approved training on the regulation Prohibited Health Conditions. Submit training schedule with the vendors name. date of schedule. Upon completion submit the training material and staff sign in sheet.
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Based on staff interviews and review of medical records the licensee retained resident
with Stage III pressure injuries. This is an immediate health and safety risk to residents in care.
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20240521090631
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEACEFUL KINGDOM HOME CARE I
FACILITY NUMBER: 197610244
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2024
Section Cited
CCR
87463(a)
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Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary....... the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical...
This requirement is not met as evidenced by:
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Administrator agreed to submit a statement of understanding on how all residents will have a proper reappraisal when changes occur and coming out of the hospital to ensure their needs are met. Proof of statement shall be submitted to LPA by POC date.
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Based on interview and record reviews, licensee did not comply with the section cited above. Administrator confirmed that upon R1's discharge from the hospital on 05/12/24 and 05/15/24, R1's reappraisals were not updated, which poses/posed a potential health and safety risk to resident in care.
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Type B
12/02/2024
Section Cited
CCR
87405(d)(1,2)
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Administrator Qualifications - 87405 (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator... (1) Knowledge of the requirements...
This requirement is not met as evidenced by:
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Licensee agrees to follow proper guidelines for Administrator Qualifications. LPA discussed with the Administrators’ section 87405. Licensee agrees to submit a written letter to CCL indicating that they have read the regulations, have full understanding.

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Based on interviews, the licensee failed to ensure that the administrator had knowledge of licensing rules and regulations which poses a health and potential safety risk to the residents in care.
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6