197610258-9-15-2022-31-AS-EMIR-CK5PQU-20221012113141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610258
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:51:28 PM

Unsubstantiated

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
09/07/2022 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20220907135752

FACILITY NAME:	HOME FOR THE ELDERLY		FACILITY NUMBER:	197610258
ADMINISTRATOR:	GACAYAN, CAMERON		FACILITY TYPE:	740
ADDRESS:	19825 LEADWELL ST.		TELEPHONE:	(818) 718-2750
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 4	DATE:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Francisco Fabrigas, Cameron Gacayan		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident is left in a soiled diaper for a long period of time.
Facility not providing food to resident.
Facility not providing drinking water to resident.
Facility not seeking medical treatment for resident.
Facility not allowing resident to leave facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with administrators Francisco Fabrigas and Cameron Gacayan and explained to both of them the purpose of the visit. During the course of the investigation, interviews and record review were made.

Resident is left in a soiled diaper for a long period of time:
In regards to the allegation, both administrators confirmed and acknowledged that Resident 1 (R1) is incontinent. As part of the incontinent care plan, staff would check up on R1 every two hours, and provide a change of diaper when needed. R1 was also given a bell so that when assistance needed, R1 would use the bell to cal for assistance. One of one staff was interveiwed and staff confirmed that they provided incontinent care for R1 and denied ever leaving R1 soiled in their diaper. Staff also provided the LPA with a service log to indicate every time R1 was provided assistance for their incotinent care. Furthermore, three

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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-20220907135752

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: HOME FOR THE ELDERLY	FACILITY NUMBER: 197610258
	VISIT DATE: 09/15/2022

NARRATIVE

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out of three residents that require incontinent care has never complained of ever being left soiled or not being provided assistance with going to the bathroom. Based on the information obtained, there was insufficient evidence to corroborate the allegation of R1 being left soiled in their diaper for a long period of time. Therefore the allegation is deemed Unsubstantiated at this time.

Facility not providing food to resident:
In regards to the allegation, according to both administrators, R1 required a special diet because R1 had a hard time swallowing food. Mr. Fabrigas stated R1 would prefer to have apple sauce, chicken noodle soup and chocolate pudding, which facility kept a supply of. Furthermore, Mr Fabrigas stated he has purchased a blender to blend some of R1's food to help with R1's food intake. Both the administrators and staff deny the allegation of not providing R1 food. Four of four residents have no complaints of never being provided food during their stay at the facility. Based on the information obtained, there was insufficient evidence to corroborate the allegation of food not being provided to resident. Therefore the allegation is deemed Unsubstantiated at this time.

Facility not providing drinking water to resident:
In regards to the allegation, both administrators confirmed that R1 always had a large cup of water with a straw next to them. R1 is no longer at the facility, but on a previous complaint investigation, LPA did interview R1 and did observe a large cup of water with a straw with R1 in their room. Both administrators and staff deny the allegation. Four of four residents have no complaints of never being provided drinking water. Based on the information obtained, there was insufficient evidence to corroborate the allegation of water not being provided to residents. Therefore the allegation is deemed Unsubstantiated at this time.

Facility not seeking medical treatment for resident:
In regards to the allegation, according to Mr. Fabrigas, on or around 9/4/22, R1's family came to facility and deemed that R1 needed medical attention. The fire department, paramedics and law enforcement responded to this request for assistance, and both the paramedics and law enforcement deemed that R1 did not require immediate medical attention. Furthermore, R1 is receiving hospice care and has a DNR

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20220907135752

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: HOME FOR THE ELDERLY	FACILITY NUMBER: 197610258
	VISIT DATE: 09/15/2022

NARRATIVE

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on file. As part of the hospice care plan, hospice needs to be notified of immediate medical attention, which was not required at that time based on the paramedics, and law enforcement assessment. Law enforcement had to pull R1's family aside to advise them of the assessment and situation of R1 not needing immediate medical attention. Copy of R1's records and an incident report obtained reflecting this incident. Based on the information obtained, there was insufficient evidence to corroborate the allegation of facility not providing medical attention to resident. Therefore, the allegation is deemed Unsubstantiated at this time.

Facility not allowing resident to leave facility:
In regards to the allegation, according to both administrator and staff, residents are allowed to come and go as they please if their physician's report indicate they can leave facility unassisted. If a resident needs assistance when leaving the facility, they are still allowed so, as long as supervision, or a relative accompanies the resident. Both the administrator and staff deny the allegation. Four of four residents expressed no complaints or concerns of not being allowed to leave the facility. Based on the information obtained, there was insufficient evidence to corroborate the allegation of facility not providing medical attention to resident. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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