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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 08/19/2022
Date Signed: 08/19/2022 03:40:41 PM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2020 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20200923102912
FACILITY NAME:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR:KIRK P KOTTHORFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:84CENSUS: 46DATE:
08/19/2022
UNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Kirk Klotthor, Executive Director/AdministratorTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Facility staff did not assist residents with hygiene needs
Residents were left in soiled clothing for an extended period of time
INVESTIGATION FINDINGS:
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On 8/19/22 at 2:24 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to deliver final findings to the facility listed above. LPA met with Kirk Klotthor, Executive Director/Administrator and explained the purpose of the visit.

On the allegations “Facility staff did not assist residents with hygiene needs” and “Residents were left in soiled clothing for an extended period of time,” the complainant’s concern was that staff were not assisting residents with showering, brushing teeth, or basic grooming. Complainant states that “residents have greasy hair, body odor, and wear the same clothes for several days.” Additionally, the complainant says residents are left in soiled clothing or briefs for an extended period of time. To investigate the allegations, LPA interviewed the staff and witness.

Continued on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
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 8
Control Number 29-AS-20200923102912
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
VISIT DATE: 08/19/2022
NARRATIVE
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.On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). S1 says “I’m not going to say we’re perfect, but it’s happened about three times in the past 10 years.” S2 says they observed “Two staff who did not attend to residents’ toileting needs for more 30 minutes.” S2 further explains that “Staff are tired from working double shifts, and sometimes they don’t tend to residents’ needs and they take naps.” S3 says they noticed “from time to time residents who had bowel movement accidents.” S3 says this topic was discussed in crossover meetings, and S3 says “If a manager told staff to change a resident’s diaper, they would change it, but if anyone else told staff, they would wait to change the diaper.” S3 did not specify how long staff waited.

On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed Staff #4 (S4) and Staff #5 (S5). S4 reports that it is discussed with staff in crossover meetings. S4 says they do not know of any staff who had problems with changing residents. S5 says “It happens sometimes. Staff may be helping other residents,” but S5 says they do not recall any staff in particular who did this.



On 8/11/22 at 1:22 pm, LPA spoke with Witness #4 (w4). W4 says that their mother is “Typically is taken care of, however, her teeth bothered her, and staff don’t really assist with brushing her teeth.” W4 explains “Her hair looks terrible. Staff does a great job considering I don’t think they have enough people.” Other than these instances, W4 says they have had a really good experience with the facility.

Based on the evidence obtained, the allegations “Facility staff did not assist residents with hygiene needs” and “Residents were left in soiled clothing for an extended period of time” are deemed Substantiated at this time. Interviews reveal that there were occasions where staff were not assisting residents with basic hygiene needs including changing diapers in a timely manner. Deficiency cited on 9099-D.

Exit interview conducted, deficiency cited, and a copy of the report and appeal rights emailed to the administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20200923102912
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Administrator will read the regulation and submit a Statement of Understanding to CCL by 8/22/22. Administrator will schedule Personal Rights training with all staff by 8/22/22 and send CCL a copy of the training sign-in sheet by 8/29/22.
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Based on interviews, the facility did not ensure that adequate personal hygiene measures were in place to keep residents healthy which poses 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2020 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20200923102912

FACILITY NAME:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR:KIRK P KOTTHORFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:84CENSUS: 46DATE:
08/19/2022
UNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Kirk Klotthor, Executive Director/AdministratorTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Facility staff are not properly trained
Facility staff who are not appropriately skilled professionals are conducting medical assessments
Residents are sustaining multiple falls
INVESTIGATION FINDINGS:
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On 8/19/22 at 2:24 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to deliver final findings to the facility listed above. LPA met with Kirk Klotthor, Executive Director/Administrator and explained the purpose of the visit.

On the allegation “Facility staff are not properly trained,” the complainant was concerned that there are staff members dispensing medications who are who are not properly trained to do so. On the allegation “Facility staff who are not appropriately skilled professionals are conducting medical assessments,” the complainant’s concern was that staff who are not appropriately skilled have been conducting medical assessments, providing wound care and "performing nursing duties."


Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20200923102912
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
VISIT DATE: 08/19/2022
NARRATIVE
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On 9/25/20 at 2:59 pm, LPA interviewed Kirk Klotthor, Administrator. Administrator said the facility has a “standard program for training” new employees. He explains they start with learning the program, then shadowing. He was unsure how long the shadowing took place.

On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed S1, S2, and S3. S1 says “Caregivers may give information on a resident to med-techs, but I’ve never seen or heard someone giving medications that was not trained.” S2 and S3 say they “do not have any knowledge of this.”

On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed S4 and S5. S4 states that “Caregivers don’t touch meds, they only take care of residents. Med-techs do medical assessments, if residents have a wound or skin tear. They take care of it or wait until the LVN gets to it.” S5 reports that “If a nurse is not in the facility, med-techs will assess a resident fall. Any unwitnessed falls, staff always call emergency services.” S5 says that the LVN is required to do an assessment, if they’re in the building and when they’re not there, med-techs do the assessment.”



On 8/11/22 between 10:50 am and 1:22 pm, LPA interviewed W1, W2, W3, and W4. W1 relays that “For the most part, everyone I’ve met is trained and real nice. One staff didn’t seem adequately trained to answer my questions when my mom had head lacerations.” W1 says they spoke with staff about preventing injuries, and staff talked about the possibility of using restraints.” W2 reports they have never seen a problem. They say “If I have questions, I go to the wellness room or call and talk to a med-tech.” W2 says “Covid was not good to the old people. Visits were limited.” W3 comments that staff are “mostly trained” and says “It’s about being positive and they (staff) are that way in situations where someone could get discouraged, for example, somebody who’s changing residents’ diapers several times a day.” W4 states that staff “Need more training” and describes a situation where their mom was in a wheelchair. W4 says “Staff brought her out in her wheelchair without feet support. This is a no, no. She could slip out.” W4 says they have had to remind staff about this. W4 speaks of a time when “Mom’s garbage can had a dirty diaper in it and there was poop on the side of the toilet. The room smelled badly. Staff dealt with right away once I mentioned it. Chalk it up to not really caring. Generally, staff is responsive and responsible.”

On 8/18/22 at 10:15 am, LPA interviewed W5. W5 says “Staff is qualified, the ones I see, but they need more staff.”

Continued on 9099-C.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20200923102912
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
VISIT DATE: 08/19/2022
NARRATIVE
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On 8/19/22, LPA reviewed the facility’s Medical Emergencies policy which states “Caregivers summon 911 should a resident exhibit signs and symptoms of a medical emergency.” Additionally, it says “The community summons emergency medical services by calling 911 when the resident exhibits signs and systems of distress and/or emergency condition.” Several examples of conditions are listed where “the community” addresses these situations.

On the allegations “Facility staff are not properly trained,” and “Facility staff who are not appropriately skilled professionals are conducting medical assessments,” are deemed Unsubstantiated at this time. Interviews and records review reveal that only med-techs and LVNs are dispensing medications and providing medical care.


On the allegation “Residents are sustaining multiple falls,” the complainant’s concern was that there had been a “high number of unattended falls" at the facility. To investigate, LPA interviewed the administrator, staff, and witnesses, and reviewed records.



On 9/25/20 at 2:59 pm, LPA interviewed Kirk Klotthor, Administrator. Administrator says there are “a few” resident falls per month, possibly three (3) or more. He says he thinks there “aren’t that many falls.” He says minor falls are when “staff witnessed the fall and caught the resident.” He says when a fall is unwitnessed, the resident is “sent out” to the hospital. He says he completes about 10-15 incident reports per month.

S1 reports “We have frequent falls because of dementia, but no more than usual in 2020. It was a crazy time, we were short staffed and it may have been a problem with more falls and staff leaving.” S2 says they did not think there were a lot of falls in 2020.

S3 says residents have chair alarms and some staff do not want to check on them. S3 says “There are a handful of staff who were good about checking on residents and that the new, inexperienced staff didn’t care to follow residents with a fall risk down the hall.” S3 says they have seen residents fall because staff were not around to assist.” S3 further explains that “Residents don’t want to use their walkers or don’t like being touched so now caregivers can be close by and residents still fall.” S3 also reports that “Staff are on their phones too much and not paying attention to residents.”

Continued on 9099-C.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20200923102912
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
VISIT DATE: 08/19/2022
NARRATIVE
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S4 says that in 2020, they don’t remember a lot of falls. S4 says they feel like there are “more falls now.” S4 explains residents have chair alarms so staff know when residents are getting out of their chairs. Staff does garden checks every 30 minutes where they go out to the garden and outdoor patios to check on residents. S4 explains that there are three caregivers and one concierge in each neighborhood, and that the concierge watches the common area, helps with resident falls, and checks on residents in the garden.” S4 says “Residents sometimes ask if they can go outside and this helps notify staff where residents are.” S5 says they believe there are the same number of falls now as in 2020 and that there are more falls outside now due to good weather.

W1 says that their mom had nine unwitnessed falls in 2022. W1 explains that “Staff was trying to take a blanket from her and it ended up in a fall.” W1 also explains that “Mom went through a spell of falling for no reason.” W2 says “Mom has fallen a couple of times. One time she hurt her arm.” W2 says that both times, staff called W2 immediately. W2 comments that their mom’s evaluations state that she’s a fall risk. W2 says “As people age, people fall. I took her for a drive and after 2 hours in the car, she’s exhausted, a bit stumbling, and losing her footing.”


W3 says “Staff know the residents who need assistance. My sister hasn’t had any falls.” W4 says their mom fell twice. W4 states that staff “Didn’t remember that she couldn’t walk. Staff sometimes forget to put her guard rails up. They called and let me know as soon as it happened. I checked on her the next day and she was fine.” W5 says their mom “Falls quite a bit” and describes that “A couple of weeks ago, she fell four days of the week.”

On 8/18/22, LPA reviewed the facility’s incident reports for falls between January and September 2020. In this time period (9 months), there was a total of seventeen (17) falls, an average of 2 per month, 8 attended and 9 unattended. The average census was 53. In comparison, the facility had thirty (30) falls in the previous 9 months (April to December 2019), an average of 3.3 falls per month with an average census of 61, 11 attended and 19 unattended. The facility had a 13% decrease in residents and a 43% decrease in the number of falls from January to September 2020 than from the previous 9 months.

Based on evidence obtained, the allegation “Residents are sustaining multiple falls,” is deemed Unsubstantiated at this time. Interviews and records review indicate that residents did not have an unusually large quantity of unattended falls during the time period of concern.



Exit interview conducted and a copy of the report emailed to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8