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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801016
Report Date: 04/07/2022
Date Signed: 04/07/2022 05:21:32 PM



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
04/15/2021 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20210415142413
FACILITY NAME:VILLA RIVIERAFACILITY NUMBER:
425801016
ADMINISTRATOR:CAROL PRAGERFACILITY TYPE:
740
ADDRESS:1621 GRAND AVENUETELEPHONE:
(805) 568-5840
CITY:SANTA BARBARASTATE: CAZIP CODE:
93103
CAPACITY:20CENSUS: 8DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Dan ThomasTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Toan Luong conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Dan Thomas, Administrator Director of Nursing and explained the reason for the visit.

On 04/15/2021, the Department received a complaint regarding an allegation that facility Resident #1 (R1) did not receive medical attention in a timely manner after R1 was found to have sustained an injury to the right foot. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Jose Santana.
On 04/16/2021, from 9:30am to 12:00pm, Licensing Program Analyst (LPA) Mark Jeffries conducted an unannounced initial 10-day complaint investigation visit. At 9:35am, Administrator, Carol Prager and LPA Jeffries toured the facility and observed 10 residents present at the facility. At 9:45am, LPA and Administrator toured R1’s room. LPA obtained copies of pertinent documents.
(Continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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 6
Control Number 29-AS-20210415142413
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: VILLA RIVIERA
FACILITY NUMBER: 425801016
VISIT DATE: 04/07/2022
NARRATIVE
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(Pg2) At 10:21am, LPA photographed R1's right foot and right palm of hand. LPA conducted a cursory interview with Administrator and informed the complaint was referred to the Investigations Branch (IB) for review. LPA determined further investigation was required.
On 04/22/2021, Investigator Santana conducted an interview with R1’s representative; on 04/26/2021, with Santa Barbara Long Term Care Ombudsman; on 05/06/2021, with R1’s Podiatrist, Administrator and staff. The investigator attempted to interview R1, however, R1 did not qualify for the interview due to R1 provided incorrect answers to cursory questions. On 05/18/2021, the investigator conducted a follow up interview with R1’s representative; on 06/03/2021, conducted an interview with assistant Administrator and staff; on 06/04/2021, with staff and a follow-up interview with Administrator; and on 06/09/2021, a 2nd follow-up interview with R1’s representative.
Investigator Santana reviewed copies of facility records and medical records related to R1. The information indicated R1 was admitted to the facility on 03/15/2021. The pre-placement appraisal, dated 03/15/2021, noted R1 as being a fall risk due to unsteady with cane; mental condition was described as “mild dementia” and forgetfulness; would require stand-by assistance with transferring and would receive room checks every two hours. The physician report, dated 02/23/2021, noted R1 as having “mild dementia”, had no motor impairment, and was able to follow directions. Additionally, the Investigator reviewed the Unusual Incident Report for the 04/09/2021 unwitnessed fall and obtained photos of R1’s injured right foot.
On 04/09/2021, at 8:13am, staff reported that R1 complained of pain in the right foot, which had a small purple bruise. This was also reported to R1’s representative. R1 reported falling at 3:00am. that morning. The overnight staff reported that R1 was in bed during each round prior to the injury. At 8:30am an ice pack was applied. R1 was able to ambulate with a cane after the injury was observed. R1’s representative visited on 04/14/2021 and decided to have R1 seen by a doctor. On 04/15/2021, examination of the right foot by the primary care physician, six days after the injury, revealed continued swelling and bruising. X-rays revealed R1 sustained a displaced oblique fracture through the fifth metatarsal with overriding of fracture fragments. The facility sought no medical attention even though R1 has dementia and could not accurately describe the circumstances resulting in R1’s injuries. While there is some evidence from caregiver statements that the facility iced the injury and took measures to try to prevent further falls, the facility failed to follow its own protocol of notifying a doctor after a resident injury. (Continued on 9099C)
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210415142413
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: VILLA RIVIERA
FACILITY NUMBER: 425801016
VISIT DATE: 04/07/2022
NARRATIVE
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(Pg3) Based on the information obtained, the allegation that the facility failed to obtain timely medical attention is deemed substantiated at this time.
Exit interview conducted, deficiencies cited on 9099-D, appeal rights emailed, and a copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20210415142413
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: VILLA RIVIERA
FACILITY NUMBER: 425801016
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2022
Section Cited
CCR
87465(1)
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87465 (1) Incidental Medical and Dental Care (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement is not met as evidenced by: Licensee did not notify Dr. when R1 fell

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Administrator Prager had reviewed policy with staff following incident. Diretor of nursing will submit documentation to LPA by 4/11/22. POC is cleared pending submission proof.
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on 04/09/2021 and observed R1 right foot bruised. R1’s Representative took R1 to the Dr. on 04/15/2021, where it was revealed R1 sustained a fracture of right foot, which posed 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: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
04/15/2021 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20210415142413

FACILITY NAME:VILLA RIVIERAFACILITY NUMBER:
425801016
ADMINISTRATOR:CAROL PRAGERFACILITY TYPE:
740
ADDRESS:1621 GRAND AVENUETELEPHONE:
(805) 568-5840
CITY:SANTA BARBARASTATE: CAZIP CODE:
93103
CAPACITY:20CENSUS: 8DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Dan ThomasTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff makes inappropriate comments towards resident.
Staff are retaliating against resident.
Facility phone voicemail is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Toan Luong conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Dan Thomas, Administrator Director of Nursing and explained the reason for the visit.
On 04/16/2021, from 9:30am to 12:00pm, Licensing Program Analyst (LPA) Mark Jeffries conducted an unannounced initial 10-day complaint investigation visit. At 9:35am, Administrator, Carol Prager and LPA Jeffries toured the facility and observed 10 residents present at the facility. LPA determined further investigation was required.
Between 8/26/21 through 10/1/21, LPA Luong interviewed staff and residents responsible party over the telephone. On 4/4/22, LPA Luong interviewed residents at the facility. Interviews conducted during that time did not reveal that staff had made inapproriate towards residents. However, interviews does reveal that the demeanor of Administrator Prager was blunt and not tactful in some instances where staff felt that interpersonal skill could be improved on. (Contiuned on 9099C).
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20210415142413
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: VILLA RIVIERA
FACILITY NUMBER: 425801016
VISIT DATE: 04/07/2022
NARRATIVE
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Based on interviews, Staff made inappropriate comments is deemed to be unsubstantiated at this time.
Furthermore, interviews among staff, residents, and responsible parties at the time did not indicate staff retaliated against residents. Based on interviews, Staff retaliated against residents is unsubstantiated at this time
On 4/4/22, LPA Luong contacted the facility telephone number. LPA was greeted by a voicemail prompting the caller to call the back line, which was revealed as the kitchen line in interviews among staff, to reach a caregiver. The voicemail also suggest that callers call the back line on weekends and after 5 p.m. on weekdays. After the voicemail ended, there was a beep for a message to be left. Based on observation, facility voicemail is in disrepair is deemed to be unsubstantiated at this time

LPA conducted exit interview and emailed report to the facility.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6