405850249-5-29-2024-29-AS-KBUY-D5RSSC-20240530140743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850249
Report Date: 05/29/2024
Date Signed: 05/29/2024 08:14:24 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
03/13/2023 and conducted by Evaluator Erika Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230313084129

FACILITY NAME:	INGLESIDE ASSISTED LIVING		FACILITY NUMBER:	405850249
ADMINISTRATOR:	DAUGHERTY, NIKOLE		FACILITY TYPE:	740
ADDRESS:	10630 WEST FRONT ROAD		TELEPHONE:	(805) 460-6541
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	16	CENSUS: 16	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Nikole Daugherty, Administrator		TIME COMPLETED:	08:24 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to neglect, Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Miller conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Nikole Daugherty, Administrator on May 29, 2024 and explained the purpose of the visit.

During the investigation, LPA Chavez conducted an initial visit on March 15, 2023 from 12:00pm to 2:50pm, toured the facility, obtained documents, and interviewed staff.

On the allegation: Due to neglect, Resident sustained unexplained injuries while in care. It was alleged Resident 1 (R1) sustained bruising of unknown origin.

Resident’s family member (F1) observed R1’s body on 3/11/2023 and visited from 11:00am to 3:00pm. F1 did not observe anything occur that could have resulted in bruises. On March 12, 2023, F1 observed bruises on R1’s back and left side. F1 also stated that the bruises looked like they might be a “little old.”

(Continuned on 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: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 2

Control Number 29-AS-20230313084129

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: INGLESIDE ASSISTED LIVING	FACILITY NUMBER: 405850249
	VISIT DATE: 05/29/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed a photo of the bruising on the back. F1 also indicated on March 13, 2023, F1 was informed R1 had a “rug burn” on their knee and arm/hand. F1 stated they had observed bruises of unknown origin on R1 on previous occasions and noted R1 can be combative.

Staff interviewed indicated R1 is “highly agitated.” Staff stated R1 tries to hit, kick, bite, scratch, and spit at other residents and staff. R1 also refuses medications often. Staff stated they have tried having male and female staff assist R1, but R1 “attacks” both and has no gender preference. Staff stated they do not know how R1 got the bruises. Staff stated R1 had not fallen and had not seen a physical altercation to cause the bruises. Staff stated they did not believe any staff, resident, or visit caused the bruises, and staff would not allow that to happen. Staff stated R1 receives the assistance of two staff for Activities of Daily Living (ADLs) including changing clothes, changing brief, showering, brushing teeth, and washing face. Administrator stated after an incident on February 21, 2023, R1 was assessed by a physician who changed their medications and suggested bed rails and a tab alarm on clothing to alert staff to movement. Administrator also stated R1 was put on hospice. R1 did not have a one-on-one staff observing them at all times.

LPA reviewed Incident Reports for R1. LPA did not observe any incident reports from around the time the bruise was observed.

The investigation did not find sufficient evidence to prove that R1 sustained bruising as a result of staff neglect. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2