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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 05:25:08 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
05/14/2021 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20210514082941
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:
04:40 PM
MET WITH:Dan ThomasTIME COMPLETED:
05:35 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 05/14/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility Resident #1 (R1) did not receive medical attention in a timely manner after R1 sustained a fall and injured arm. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Jose Santana.
On 05/17/2021, from 10:30am to 11:30am, Licensing Program Analysts (LPAs) Darlene Chavez and Toan Luong conducted the initial 10-day complaint visit and met with Carol Prager, Administrator and Dan Thomas, Administrative Director of Nursing. During the visit, LPAs toured the facility with Administrator and requested documents pertinent to the investigation.
(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-20210514082941
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) The Administrator was notified that the complaint was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Jose Santana. On 05/20/2021, Investigator Santana conducted an interview with R1’s representative and Witness #1 (W1); on 05/24/2021, with R1’s primary care physician; and from 06/03/2021 to 06/04/2021, with facility staff, Administrator and Assistant Administrator.
Investigator Santana reviewed copies of facility records and medical records related to R1. The information indicated R1 was admitted to the facility on 02/23/2021. The physician report, dated 01/26/2021, listed the primary diagnosis as late onset Alzheimer’s disease with behavioral disturbance, and secondary diagnoses of multifactorial gait disorder and physical deconditioning. R1 was noted as being confused and unable to following instructions, and having inappropriate, aggressive, and wandering behaviors. R1 required assistance with transferring and ambulating. R1 had a history of hip fracture and arthritis. Additionally, the Investigator reviewed the Unusual Incident Report for the 04/14/2021 fall, progress notes, 24-hour shift reports, and photos taken of R1’s injury on 04/15/2021 and 04/16/2021. The photos show R1’s entire right upper arm was bruised and swollen.

On 04/14/2021, at approximately 8:00pm, R1 resisted the assistance of two caregivers, Staff #1 (S1) and Staff #2 (S2), with being placed in bed, and insisted they leave R1’s bedroom. At approximately 8:30pm, staff heard the floor mat alarm and found R1 on the floor by bed. S1 and S2 helped R1 off the floor and into bed. R1 was uncooperative, yelled and denied pain. Staff did not note any injury in progress notes or shift reports. The staff did not notify the on-call facility nurse, R1’s representative or the physician’s office, as is the facility’s protocol for falls. There was no documentation of a fall in the 04/14/2021 24-hour shift reports.

On 04/15/2021, at 8:45am, R1 was given Tylenol for discomfort. R1 was noted to have a large bruise on arm and would not move arm. At 11:00am, the Administrator met with R1’s representative, after which R1’s representative called R1’s primary care physician. X-rays were taken at 1:00pm revealed R1 had a mildly comminuted displaced fracture of the right humeral head and upper surgical neck without dislocation. R1 was admitted to Cottage Hospital on 04/15/2021 due to the shoulder fracture. R1’s representative opted for conservative treatment and R1’s right arm was placed in a sling. R1 was discharged on 04/21/2021 to skilled nursing facility for rehabilitation. (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-20210514082941
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) The facility caregivers were aware R1 sustained a fall but they did not notify the on-call facility nurse, R1’s representative, or the physician’s office. Furthermore, there was no assessment for the injury and no medical attention was immediately sought. On the morning after the fall, 04/15/2021, when Staff #3 (S3) noticed the injury on R1’s arm, S3 also did not report anything to the facility nurse until at least an hour later. The facility nurse forgot to assess R1, and it was not until R1’s representative arrived at the facility that any action was taken to address the injury. Based on the information obtained, the allegation that the facility failed to obtain timely medical attention because of neglect/lack of supervision is deemed substantiated at this time.

Exit interview conducted, deficiency cited on 9099-D, appeal rights discussed, 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-20210514082941
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: The facility did not notify R1’s physician 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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and observed R1 right arm bruised, and medical attention was only sought after R1’s Representative contacted the Dr. on 04/15/2021, where it was revealed R1 sustained a fracture of right shoulder, 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
05/14/2021 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20210514082941

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:
04:40 PM
MET WITH:Dan ThomasTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Resident sustained a fracture due to lack of care and supervision
Staff made inappropriate comments
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 05/14/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility Resident #1 (R1) sustained a fractured shoulder as a result of facility neglect/lack of supervision. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Jose Santana.
On 05/17/2021, from 10:30am to 11:30am, Licensing Program Analysts (LPAs) Darlene Chavez and Toan Luong conducted the initial 10-day complaint visit and met with Carol Prager, Administrator and Dan Thomas, Administrative Director of Nursing. During the visit, LPAs toured the facility with Administrator and requested documents pertinent to the investigation. The Administrator was notified that the complaint was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Jose Santana. (Continued 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-20210514082941
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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On 05/20/2021, Investigator Santana conducted an interview with R1’s representative and Witness #1 (W1); on 05/24/2021, with R1’s primary care physician; and from 06/03/2021 to 06/04/2021, with facility staff, Administrator and Assistant Administrator.
Investigator Santana reviewed copies of facility records and medical records related to R1. The information indicated R1 was admitted to the facility on 02/23/2021. The physician report, dated 01/26/2021, listed the primary diagnosis as late onset Alzheimer’s disease with behavioral disturbance, and secondary diagnoses of multifactorial gait disorder and physical deconditioning. R1 was noted as being confused and unable to following instructions, and having inappropriate, aggressive, and wandering behaviors. R1 required assistance with transferring and ambulating. R1 had a history of hip fracture and arthritis. Additionally, the Investigator reviewed the Unusual Incident Report for the 04/14/2021 fall, progress notes, 24-hour shift reports, and photos of R1’s injured arm.
On 04/14/2021, at approximately 8:00pm, R1 resisted the assistance of two caregivers, Staff #1 (S1) and Staff #2 (S2), with being placed in bed, and insisted they leave R1’s bedroom. At approximately 8:30pm, staff heard the floor mat alarm and found R1 on the floor by bed. S1 and S2 helped R1 off the floor and into bed. R1 was uncooperative, yelled and denied pain. No injuries were noted at the time.
According to Investigator Santana, there appears to be an element of neglect in that caregivers did not know how to adequately address R1’s aggression, which may have been the root cause of the fall, but R1 was a known fall risk and was liable to fall at any time despite facility fall precautions. Based on the information obtained, there is not sufficient evidence to support the allegation, therefore the allegation Facility Resident #1 (R1) sustained a fractured shoulder as a result of facility neglect/lack of supervision is deemed unsubstantiated at this time.
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 inappropriate 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. Based on interviews, staff made inappropriate comments is unsubstantiated at this time.
Exit interview conducted, appeal rights 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: 6 of 6