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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801723
Report Date: 10/03/2024
Date Signed: 10/03/2024 01:34:30 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
09/20/2024 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20240920132523
FACILITY NAME:PRIMROSEFACILITY NUMBER:
425801723
ADMINISTRATOR:DOROTHY BERGERFACILITY TYPE:
740
ADDRESS:4630 SONG LANETELEPHONE:
(805) 310-6996
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:14CENSUS: 13DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yuribeth Reyes, Medical Technician (MedTech)TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility charging resident for services not provided in admission agreement addendum
INVESTIGATION FINDINGS:
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On 10/03/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Medical Technician (MedTech) Yuribeth Reyes as the Administrator was unavailable, and explained the reason for the visit.

On the allegation: Facility charging resident for services not provided in admission agreement addendum. Due to Resident #1 (R1) requiring lengthy time bathing, grooming, and dressing, along with extra trips to the bathroom, an addendum to R1’s admission agreement was signed and dated for an increase in fee for R1 due to an extra 60 minutes of toileting, an extra 85 minutes for personal care, and bathing with stand by assist. It is alleged that after the signing of the addendum, the facility is leaving R1 unsupervised during activities of daily living, not following fall risk guidelines. The allegation would like the total increased amount of money charged to R1 from the addendum be returned to R1 and their representative(s) as the facility is not allegedly providing the services charged in the addendum. Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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 4
Control Number 29-AS-20240920132523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIMROSE
FACILITY NUMBER: 425801723
VISIT DATE: 10/03/2024
NARRATIVE
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On 09/26/2024, LPA conducted a complaint investigation visit to the facility above. During this visit, LPA interviewed credible witnesses to the allegation in the complaint. LPA also requested and received relevant documentation pertinent to the allegation for record review. LPA reviewed R1’s Physicians Report for Residential Care Facilities for the Elderly (RCFE). The Physicians Report for R1, dated 02/24/2024, stated that R1 has difficulty walking and weakness of the musculoskeletal system. R1 is listed as having mild cognitive impairment, with cognitive abilities between normal aging and dementia. R1 has a mental condition listed by the physician as being slightly confused/disoriented at times. The physician listed R1’s capacity for self-care as being unable to bathe self without assistance, unable to dress/groom self without assistance, and needing assistance with toileting needs. The ambulatory status of R1 is non-ambulatory based on physical condition and mental condition. LPA received the documented facility Preplacement Appraisal information for R1 dated 06/10/2024. The Preplacement Appraisal information for R1 states that R1 has physical limitations including needing a walker for assistance due to a history of fall and foot injury. R1 was deemed a fall risk by the facility. R1’s functional capabilities were listed as requiring personal help for mobility and needing a walker and/or wheelchair which R1 needed assistance entering/exiting. R1 has documented services needed from the facility with transferring in and out of bed and dressing, help with bathing, hair care, and personal hygiene. R1 is documented to need facility staff to assist with toileting, including assistance equipment and assistance of another person. The admission agreement considerations of R1, documented by the facility on 06/11/2024, indicate that R1 had a sprained left foot with drop foot and left leg nerve damage due to a recent fall. Both the Preplacement Appraisal and Admission Agreement of R1 indicate that R1 dislikes being perceived to be rushed while conducting Activities of Daily Living (ADL) including bathing, grooming, and toileting.

LPA conducted review of facility records that indicated approximately two (2) months after R1 was admitted to the facility, an addendum was signed and dated between the facility and R1’s Responsible Party for an increase in fee for R1 due to an extra 60 minutes of toileting, an extra 85 minutes for personal care, and bathing with stand by assist. Documented communication between the facility and representatives of R1 on 07/30/2024 and 07/31/2024 indicated that representatives for R1 stated that R1 was independent and can bathe alone until needing to be taken back to their room. R1’s representatives also stated that R1 should be left alone when toileting aside from transportation and left alone when grooming and putting on their own footwear. The Responsible Party of R1 requested the facility leave R1 unsupervised for periods of time while R1 is bathing, grooming, dressing, and toileting with facility caregivers checking in on R1 sporadically instead of constant stand by supervision of R1. Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20240920132523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIMROSE
FACILITY NUMBER: 425801723
VISIT DATE: 10/03/2024
NARRATIVE
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The facility communicated to the representatives of R1 that R1 required an additional 1-2 hours of shower time, and an additional 85-90 minutes of personal care. The facility indicated that the physical care of R1 takes an inordinate amount of time, which prevents staff from providing the same care to other residents. The facility also stated to the representatives of R1 that they are interfering with the ability of the facility to provide care to all residents with the frequent and sometimes conflicting requests for R1. On 09/13/2024, the facility communicated with representative(s) of R1 that R1 warrants a one-to-one caregiver at the expense of the Responsible party due to R1’s care needs, but this has not been provided at the time of this report. The facility stated that it is extremely difficult to stay with R1 for hours at a time as there is a limited number of staff and up to 13 other residents in the facility. The facility communicated that security camera footage shows the longest timespan between staff checks on R1 overall was 9 minutes in the facility, but that during ADLs R1 had stand by assistance from staff.

Documented facility Narrative Charting from July 2024 and August 2024 indicates that R1 is on 15-minute monitoring by facility staff overnight and that R1 would use a bell alert system from their room to notify staff they needed to use the restroom 1-2 times overnight. Narrative charting from the facility also documented procedures for bathing R1 including transferring R1 from their wheelchair into a shower chair, turning on the water, and handing R1 the hygiene products. Narrative charting indicates that facility staff would stand by as R1 would wash/clean themselves. Staff would turn off the water for R1, assist with providing R1 a towel to dry themselves, and assist R1 with putting on clothing and footwear. Facility narrative charting from 07/16/2024 indicated that R1 spent 1 hour in the shower with the Responsible Party of R1 observing the entire time. Facility staff conducted stand by assist supervising R1 bathe. On 07/22/2024, facility narrative charting indicated that facility staff, a physical therapist for R1, and R1’s Responsible Party all observed R1 bathing/showering as staff were told that R1 can wash themselves and dress themselves independently, but with visual supervision. This bathing/shower lasted approximately 50 minutes. On 07/31/2024, narrative charting indicated that the responsible party of R1 stated to staff that R1 cannot be left alone during ADLs. On 08/05/2024, narrative charting indicated that R1 was observed by their responsible party during the supervised and assisted bathing/showering by facility staff from approximately 7:20am-8:15am. On 08/06/2024, narrative charting by the facility indicated that R1 requested to go to the bathroom at 6:30am and was left alone for a few minutes after transferring R1 as they were seated on the toilet, but they were then supervised by staff. The narrative charting indicates after toileting, R1 was able to conduct their personal care independently with stand-by supervision. At 7:45am, R1 was returned to their bedroom until 8:15am, with staff going back and forth checking on R1 frequently. Contd. 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20240920132523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIMROSE
FACILITY NUMBER: 425801723
VISIT DATE: 10/03/2024
NARRATIVE
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Staff interviewed by LPA stated that when speaking with the Responsible Party of R1, they indicated that some residents can be left alone when bathing/grooming, but certain residents including R1 needed stand by assistance from staff as they were fall risks. According to staff interviewed by LPA, the Responsible Party for R1 visited the facility and stated to staff that R1 cannot be left alone during ADLs such as bathing/grooming. Staff interviewed by LPA stated that at certain times when the Responsible Party of R1 would visit the facility, staff were told by the Responsible Party not to assist R1 with drying themselves after bathing/grooming as staff were told by the responsible party that R1 could do that themselves. Staff interviewed by LPA indicated that providing R1 with stand-by assistance means that R1 is provided with a type of support where staff remain close to R1 to help prevent falls or injuries. Staff stated to LPA that stand-by assist is not touching R1 but being there to help if needed. Staff stated to LPA they do assist R1 with ADLs, but stand-by assistance is for R1 who can function on their own but may not be safe without someone nearby because of a risk of falling. Interviews by LPA with all credible witnesses indicate that stand-by assistance is conducted by facility caregivers during ADLs, when a resident can perform the actual ADL on their own, but may need a little extra help, for example, maintaining their balance or remembering the order things are done in. The stand-by assistance is maintaining proximity and supervision of the resident, not physically assisting the resident with bathing, grooming, and toileting.

It is not required in the Community Care Licensing Department (CCLD) regulations that a facility document the timeline of extra care minutes on narrative charting. However, the facility did provide narrative charting including the amount of time and procedures regarding R1’s bathing, grooming, and toileting. A representative of R1 and a therapist for R1 physically observed staff assisting with R1’s ADLs and providing stand by assistance to R1 on several occasions in July 2024 and August 2024. There is also adequate documentation that R1 is a fall risk including R1’s Physician Report, R1’s Preplacement Appraisal, and R1’s Admission Agreement. The facility provided documentation on the necessity of the increase in rate for R1 due to additional time needed for ADLs in the admission agreement addendum. The facility can charge more for providing more assistance, within Licensing regulations. All staff interviewed by LPA indicated that they had an appropriate understanding of the stand-by assistance procedure required for a resident who was a fall risk in the facility.

Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Exit interview conducted. Copy of this report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4