405801706-6-6-2024-29-AS-KBUY-D6F4PZ-20240620191733

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801706
Report Date: 06/05/2024
Date Signed: 06/06/2024 11:41:24 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
03/01/2024 and conducted by Evaluator Erika Miller

COMPLAINT CONTROL NUMBER: 29-AS-20240301164343

FACILITY NAME:	WELCOME HOME II (RCFE)		FACILITY NUMBER:	405801706
ADMINISTRATOR:	EVELYN I. FLORENTINO		FACILITY TYPE:	740
ADDRESS:	1555 16TH STREET		TELEPHONE:	(805) 439-1490
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS: 4	DATE:	06/05/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Evelyn Florentino, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not provide assistance to resident in care in a timely manner.
Staff did not provide medical assistance/PT as needed to resident in care in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit on March 6, 2024. On June 5, 2024, LPA issued final findings on the allegations above. During the investigation, LPA, Miller, toured the facility and interviewed staff on March 6, 2024, from 1:00 p.m. to 3:00 p.m. LPA also obtained and reviewed relevant documents. LPA met with Evelyn Florentino, administrator and explained the purpose of the visit.

On the allegation: Staff did not provide assistance to resident in care in a timely manner.
Resident 1 (R1) reported that they fell three days ago while transferring to wheelchair. R1 reported that they were on the floor between 2 to 4 hours waiting for assistance. R1 stated that Staff provided a blanket and pillow, but Staff refused to call the fire department "because they would investigate". R1 stated to the Ombudsman that while getting out of bed they slipped to the floor. This occurred when it was dark outside. It was daylight when two males came to assist R1 off the floor. (Cont.9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

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 29-AS-20240301164343

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELCOME HOME II (RCFE)	FACILITY NUMBER: 405801706
	VISIT DATE: 06/05/2024

NARRATIVE

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Staff stated that R1 was admitted to the facility on January 10, 2024, and stayed for nine days. Staff stated that on or about January 12, 2024, R1, called with a notification bell at approximately 7:15 a.m. Staff found R1 sitting in bed and required changing and toileting. R1 attempted to use their standing pole to transfer from bed to wheelchair, but R1 lost their balance. Staff could not support R1’s weight and advised R1 to slide slowly to the floor. R1 requested Staff call 911. Staff determined it was not necessary as R1 had no bruises or bumps and did not complain of any pain. R1 only required to be cleaned up and lifted off floor. Staff cleaned up R1 and provided R1 with a blanket and pillow. After cleaning up R1, Staff called for assistance from another caregiver at 7:45 a.m. R1 was moved into wheelchair by 8:10 a.m. R1 stated that they were okay and had no complaints of injury. There was no evidence of any injury to R1.

Administrators and staff collectively dispute that R1 fell from their bed on January 12, 2024 or that R1 was on the floor for an inordinate amount of time after sliding on to floor. On January 14, 2024, a law enforcement officer conducted a welfare check on R1. Staff stated that R1 told the officer they were fine. A police report was not filed, and the officer did not leave a business card.

Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

On the allegation: Staff did not provide medical attention/physical therapy as needed to resident in care.
It was alleged that R1 was not receiving necessary physical therapy. Staff stated that Mission Home Health of Central Coast visited the facility and provided R1 with physical therapy on two occasions. In addition, a nurse visited twice to assist with R1 wound care. R1 only resided in the facility for a total of nine days.

Staff claimed that the physical therapist advised that R1’s knee was too swollen to perform exercise. Physical therapist advised staff to ensure that R1 perform 5 repetitions of sitting to standing from wheelchair each morning. Staff advised there is no written documentation of these instructions at the facility.

Witness 2 (W2) confirmed that a nurse conducted an initial visit of R1 on January 13, 2024, and performed a subsequent visit on January 18, 2024. A physical therapist and occupational therapist conducted evaluations on January 14, 2024, and January 15, 2024, respectively.

(Cont. 9099-C)

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240301164343

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELCOME HOME II (RCFE)	FACILITY NUMBER: 405801706
	VISIT DATE: 06/05/2024

NARRATIVE

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W2 stated that there is no evidence of an exercise plan because R1 was hospitalized effective January 19, 2024. W2 further stated that clinicians were concerned that R1 required a higher level of care. R1 was ultimately moved into a skilled nursing facility. W2 advised that before admissions into facility, R1 was recovering from a left hip fracture that was surgically repaired.

Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted, copy of report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC9099 (FAS) - (06/04)

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