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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425800484
Report Date: 08/06/2021
Date Signed: 08/06/2021 03:23:03 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
12/26/2019 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20191226094333
FACILITY NAME:ABUNDANT CAREFACILITY NUMBER:
425800484
ADMINISTRATOR:TIMOTHY PRYKOFACILITY TYPE:
740
ADDRESS:5506 SOMERSET DRIVETELEPHONE:
(805) 681-1937
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 6DATE:
08/06/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lidia Kravchuk, AdministratorTIME COMPLETED:
02:51 PM
ALLEGATION(S):
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Staff inappropriately handled Resident.
Staff did not report incident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced complaint visit to the facility regarding the above allegations. During the investigation, LPA interviewed resident on 12/31/2019 at 9:45 am; interviewed staff on 12/31/2019 at 11:35 am and 8/5/2021 at 6:58 pm; and interviewed witnesses on 12/20/2019 at 10:08am, 12/26/2019 at 9:00am, 12/30/2019 at 11:29 am, and 8/5/2021 at 2:59 pm. LPA also collected and reviewed relevant documents on 12/31/2019.
Allegation #1: Staff inappropriately handled resident. Resident 1 (R1) reported that Staff 1 (S1) punched R1 three times in the ribs on or about November 25, 2019. R1 recounted the incident consistently to five separate individuals on different dates. R1 reported the incident to Staff 3 (S3) on 11/26/2019. R1 recounted the incident to Credible Witness 1 in the presence of R1’s responsible party on 12/11/2019. On 12/18/2019, R1 recounted the incident to Credible Witness 2 and R1’s friend. R1 recounted the incident to LPA on 12/31/2019. On 12/11/2019, R1 visited R1’s physician for a routine appointment. While at the appointment, R1 disclosed S1 punched R1 in the ribs. X-rays were taken and R1’s physician noted no rib fractures and observed no visible
Please continue to 9099-C, Pg 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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 5
Control Number 29-AS-20191226094333
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: ABUNDANT CARE
FACILITY NUMBER: 425800484
VISIT DATE: 08/06/2021
NARRATIVE
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contusions but observed R1’s rib area was painful when touched and noted that R1 “winced” upon touch. R1’s responsible party was present at the appointment and noted this was the first time they were hearing about the incident. R1 reported S1 punched R1 three times in the ribs. R1 screamed out S1’s name after the third punch. S1 took a step back and seemed to be “dazed” at what happened. R1 stated S1 suddenly left the facility. According to R1, when Staff 2 (S2) came on shift, S2 was not happy that S1 left a mess in the kitchen. R1 reported what occurred to S2 and that S1 had suddenly left the facility.
LPA obtained an incident report that includes an attached, unsigned declaration from S3. The declaration states on 11/26/2019, R1 reported to S3 that on 11/25/2019, S1 hit R1 in the ribs. S3 states R1 was checked and S3 observed no bruises or skin tears, and R1 reported no pain. S3 asked S1 about the incident and S1 denied touching R1. Credible Witness 2 and R1’s friend stated they believe R1 is credible and does not have a history of false statements. R1’s physician’s report dated 12/13/2018 and signed 1/1/2019 does not indicate R1 has any cognitive issues. Based on the information obtained, the allegation is Substantiated.

Allegation #2: Staff did not report incident. Prior to conducting the initial visit on 12/31/2019, LPA reviewed CCL’s incident report log and observed no incident report(s) for R1 in November 2019, and no incident report(s) indicating S1 hit R1. LPA also observed no incident reports indicating R1 embellished other incidents. During the visit on 12/31/2019, LPA obtained a written incident report for the incident on 11/25/2019, when S1 inappropriately handled R1. Administrator could not provide any verification that the incident report was sent in to CCL. In addition, the incident report does not indicate the alleged abuse was reported to the Long Term Care Ombudsman or law enforcement. The incident report also includes an attached, unsigned declaration from Staff 3 (S3). The declaration indicates R1’s responsible party was notified of the incident. However, R1’s responsible party indicated they first became aware of the incident from R1 at R1’s physician’s appointment on 12/11/2019. Over the course of the investigation, R1 passed away. Community Care Licensing did not receive a required death report from the facility for R1’s death. Based on the information obtained, the allegation “staff did not report incident” is Substantiated at this time.

At 2:41 pm, Administrator Lidia Kravchuk refused to sign Complaint Investigation Report (LIC9099, Pages 1-3.

Exit interview conducted, report given, deficiencies cited on 9099-D, appeal rights provided.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20191226094333
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: ABUNDANT CARE
FACILITY NUMBER: 425800484
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/09/2021
Section Cited
CCR
87468.1(a)(1)
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Personal Rights. Residents in all residential olcare facilities for the elderly shall have all of the flowing personal rights: To be accorded d
ignity in their personal relationships with staff, residents, and other persons..
This requirement was not met as evidenced by:
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Administrator agrees to conduct personal rights training with all facility staff. Administrator agrees to submit the date of scheduled training by 8/9/2021 and will submit proof of training by 8/13/2021.
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Based on interviews and record review, the licensee did not ensure S1 accorded R1 with dignity when S1 inappropriately handled R1, which posed an immediate health, safety, and personal rights risk to residents in care.
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At 2:41 PM, Administrator refused to sign report
Deficiency Dismissed
Type B
08/13/2021
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days… (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Administrator agreed to submit a written statement of understanding of Regulation 87211 Reporting Requirements in its entirety to CCL by 8/13/2021.
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This requirement was not by as evidenced by:

Based on record review and interviews, the licensee did not submit required written incident report/death report to CCL within seven days, which posed a potential health, safety, and personal risk to residents in care.
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At 2:41 pm, Administrator refused to sign report.
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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
12/26/2019 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20191226094333

FACILITY NAME:ABUNDANT CAREFACILITY NUMBER:
425800484
ADMINISTRATOR:TIMOTHY PRYKOFACILITY TYPE:
740
ADDRESS:5506 SOMERSET DRIVETELEPHONE:
(805) 681-1937
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 6DATE:
08/06/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lidia Kravchuk, AdministratorTIME COMPLETED:
02:51 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff retaliated against resident.
Facility failed to provide timely medical attention.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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9
10
11
12
13
Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced complaint visit to the facility regarding the above allegations. During the investigation, LPA interviewed Resident 1 (R1) on 12/31/2019 at 9:45 am; interviewed staff on 12/31/2019 at 11:35 am and 8/5/2021 at 6:58 pm; and interviewed witnesses on 12/20/2019 at 10:08 am, 12/26/2019 at 9:00 am, 12/30/2019 at 11:29 am, and 8/5/2021 at 2:59 pm. LPA also collected and reviewed relevant documents on 12/31/2019.
Allegation #1: Staff retaliated against resident. Following the incident on November 25, 2019, where R1 stated S1 hit R1, S1 continued to work at the facility and served R1 meals. R1 was concerned that S1 may have poisoned R1’s food. As a result, R1 chose to not eat food served by S1 for three days. Based on interviews conducted, there is insufficient evidence to suggest staff retaliated against R1. Therefore, the allegation is Unsubstantiated at this time.
Allegation #2: Facility failed to provide timely medical attention. At a routine doctor’s appointment, R1 disclosed that S3 punched R1. X-rays were taken and R1’s physician noted no rib fractures and observed no visible .
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20191226094333
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: ABUNDANT CARE
FACILITY NUMBER: 425800484
VISIT DATE: 08/06/2021
NARRATIVE
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contusions. However, the physician observed R1’s rib area was painful when touched and noted that R1 “winced.” There was no evidence to indicate that S3 offered to have R1 evaluated by a medical professional. Although it may have been prudent for the administrator to ensure R1 was assessed by a medical professional, R1 did not report pain and S3 stated there was no visible bruising or skin tears when a body check was conducted on 11/26/2019. Based on interviews conducted, there is insufficient evidence to prove facility failed to provide timely medical attention. Therefore, the allegation is Unsubstantiated at this time.

Exit interview, report given
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5