421700411-9-23-2022-29-AS-KBUY-CJRKVZ-20220930081510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 421700411
Report Date: 09/20/2022
Date Signed: 09/23/2022 09:03:53 AM

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
06/23/2021 and conducted by Evaluator Kristin Kontilis

COMPLAINT CONTROL NUMBER: 29-AS-20210623155841

FACILITY NAME:	VALLE VERDE		FACILITY NUMBER:	421700411
ADMINISTRATOR:	SUSAN E PONCE		FACILITY TYPE:	741
ADDRESS:	900 CALLE DE LOS AMIGOS		TELEPHONE:	(805) 883-4000
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93105
CAPACITY:	547	CENSUS: 369	DATE:	09/20/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Susie Ponce, Administrator		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Lack of supervision resulting in resident wandering away from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Olson, Cortez, and Kontilis conducted an unannounced subsequent complaint visit to issue final findings on the above allegation. LPAs met with Administrator Susie Ponce and explained the purpose of the visit. LPAs arrived at the facility at 11:15 am.
During the investigation, LPA Kontilis reviewed an incident report and other facility documents, and interviewed resident’s responsible party and staff.
Resident 1 (R1) lived at the facility since 2009, originally in Independent Living, then in Assisted Living, and then in Memory Care since January 2019.
LPA Kontilis reviewed an incident report submitted on 6/25/2021 for an incident that occurred on 6/20/2021. The incident report states on 6/20/2021 at approximately 1:00 pm, R1 exited the memory care unit. R1’s WanderGuard bracelet activated the emergency system at 1:03 pm. The resident continued walking through the campus and fell.
Please continue to 9099-C, Pg 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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 29-AS-20210623155841

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: VALLE VERDE	FACILITY NUMBER: 421700411
	VISIT DATE: 09/20/2022

NARRATIVE

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The fall was heard by a visitor who notified a nurse. At approximately 1:20 pm, the nurse responded and saw R1 was sitting on their walker and was unable to bear weight due to left hip pain. 9-1-1 was called and R1 was transported to the hospital. Due to the fall, R1 sustained a fractured pelvis. The incident report indicates an in-service training with memory care staff regarding emergency procedures, including an elopement drill, was scheduled. According to the Administrator, Staff 1 (S1) failed to fulfill their assigned duties and did not have their pager during the incident and S1 did not respond to the WanderGuard activation. S1 was terminated as a result of this incident.
Based on the information obtained, a lack of supervision resulted in R1 wandering out of the memory care unit and throughout the facility grounds. Additionally, due to the lack of supervision, R1 sustained an injury as a result of the lack of supervision. Therefore the allegation that lack of supervision resulting in resident wandering away from facility is deemed Substantiated at this time.
A $500 immediate civil penalty is assessed today. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

Exit interview conducted. Civil Penalty issued. Copy of report and Appeal Rights issued via email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210623155841

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: VALLE VERDE	FACILITY NUMBER: 421700411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/20/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) PERSONAL RIGHTS …Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	Staff were re-trained on emergency/elopement procedures on 7/7/2021. POC cleared during visit.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the above cited section when R1 eloped from the facility sustaining a fall and injury which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC9099 (FAS) - (06/04)

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