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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801995
Report Date: 12/20/2023
Date Signed: 12/20/2023 04:25:33 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
07/09/2021 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20210709080012
FACILITY NAME:ALEXANDER GARDENSFACILITY NUMBER:
425801995
ADMINISTRATOR:LEICHTER, MITCHELLFACILITY TYPE:
740
ADDRESS:2120 SANTA BARBARA STTELEPHONE:
(805) 682-9644
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:36CENSUS: 22DATE:
12/20/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Dahlia Gutierrez, Business Office ManagerTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not answer resident's call button in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings for the complaint allegation above. LPA met with Dalia Gutierrez, Business Office Manager and explained the purpose of the visit. During the investigation, LPA reviewed relevant documents and conducted staff interviews on 7/16/2021, and interviews with witnesses on 7/15/2021.

On the allegation: Staff do not answer resident's call button in a timely manner. It was alleged staff did not respond to Resident 1's (R1’s) call button in a timely manner. Staff stated call buttons were addressed in the resident council meeting held 7/16/2021. Staff stated the caregiver or med tech always respond to the call but may not reset the button. Other times, there could be a short delay when a caregiver is with another resident. Staff stated ten minutes response time is normal, and 20 minutes is the maximum. Staff stated they always see other caregivers check their pagers, and the batteries are checked often. Staff also stated

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: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
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-20210709080012
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: ALEXANDER GARDENS
FACILITY NUMBER: 425801995
VISIT DATE: 12/20/2023
NARRATIVE
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sometimes residents think they used their call button but they did not actually press it hard or long enough to call for staff. Staff stated they also have alarms in their rooms or bathrooms they can pull. Staff also stated on occasion it can take them a while to answer the door if everyone is busy helping residents with care. LPA reviewed call button logs for 5/28/2021 through 7/16/2021. LPA observed numerous calls buttons that were responded to after 20 minutes. LPA reviewed the call button logs for R1 for a two-week period from 6/1/2021 to 6/15/2021 and observed that R1 frequently used their call button, up to several times per day. LPA observed for the two-week period, there were 20 calls between 21-30 minutes response time, 10 calls between 31-40 minute response time, 4 calls with a 41-50 minute response time, 1 call with a 51-60 minute response time, and 2 calls over 60 minutes response time. Based on the information obtained, the allegation is deemed Substantiated at this time.

The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210709080012
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: ALEXANDER GARDENS
FACILITY NUMBER: 425801995
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87303(i)(1)
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87303(i)(1) Maintenance and Operation
Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall…
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Business Office Director (BOD) agrees to train staff on call response expectations for the signal system, and will send proof of training to CCL by 1/5/2023.

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This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when the signal system went unanswered for an extended period of time, which posed a potential health and safety risk to residents in care.
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BOD recommended to conduct a call response training to all staff on a quarterly basis.
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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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
07/09/2021 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20210709080012

FACILITY NAME:ALEXANDER GARDENSFACILITY NUMBER:
425801995
ADMINISTRATOR:LEICHTER, MITCHELLFACILITY TYPE:
740
ADDRESS:2120 SANTA BARBARA STTELEPHONE:
(805) 682-9644
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:36CENSUS: 22DATE:
12/20/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Dahlia Gutierrez, Business Office DirectorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff are not sufficient in numbers to provide services necessary to meet resident's needs.
Staff handle resident in a rough manner.
Resident is not accorded dignity in relationships with staff.
Facility failed to safeguard belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings for the complaint allegations above. LPA met with Dalia Gutierrez, Business Office Director and explained the purpose of the visit. During the investigation, LPA reviewed relevant documents, and conducted staff interviews on 7/16/2021, and interviews with witnesses on 7/15/2021.

On the allegation: Staff are not sufficient in numbers to provide services necessary to meet resident's needs. It was alleged that there were not enough staff to answer resident’s call buttons in a timely manner. It was also alleged that after Resident 1 (R1) slipped out of their shower chair, staff did not shower R1. Staff interviews revealed the schedule is posted two weeks in advance in an attempt to ensure adequate staffing. Staff interviews revealed they use agency staff when they are not able to fill all open positions. Staff stated residents needs are still met, but sometimes they eliminate some of the job duties such as laundry or setting tables when they are short staffed in order to focus on residents’ needs. Staff stated showers are being done
Please continue to 9099-C, Pg 2.
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: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210709080012
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: ALEXANDER GARDENS
FACILITY NUMBER: 425801995
VISIT DATE: 12/20/2023
NARRATIVE
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and care is always prioritized. Staff stated R1 had a slip and fall during a shower on the morning shift. Ever since then, R1 was a “little more afraid” or “guarded” when it came to showers. LPA reviewed shift notes on 6/16/2021 that indicate R1 showered, fell, and the fire department responded but R1 was ok. LPA reviewed shift notes on 6/19/2021 that indicated R1 refused to shower due to the fall. LPA reviewed shift notes that indicate R1 fell in the shower on 6/23/2021. R1’s physical therapist trained all shifts on how to assist R1 but staff stated R1 was still afraid to shower. This was confirmed by notes from home health occupational therapist (OT) dated 6/24/2021, the OT discussed safe transfers and the notes recommended toilet aid for toileting hygiene, and stated on the next visit they would train facility staff on showers using the shower chair. Notes from home health OT on 7/1/2021 indicate they trained caregivers and a family member on the resident using a commode. Notes from home health OT on 7/7/2021 indicates they tried a shower chair, but R1 felt the shower chair was not safe and states to continue with commode or bed bath. Staff stated though some residents require 1 person transfer assist, they had no residents at the time who were solely 2-person transfer assists. Staff stated R1 would confuse staff and call them by the wrong names. LPA observed staff schedules for June and July 2021. LPA observed one med tech and two caregivers on the AM shift, one med tech and two caregivers on the PM shift, and one med tech and one caregiver on the NOC shift. LPA observed edits made in pen to the schedule, including adding agency staff as needed. Based on the information obtained, the allegations are deemed Unsubstantiated at this time.

On the allegation: Staff handle resident in a rough manner. It was alleged that one staff handled residents roughly when assisting residents. Staff interviews stated they had not witnessed any rough handling or heard of it. Staff also stated they had not heard of it from any families/visitors. Staff stated they never heard R1 complain about staff handling them roughly or treating them without dignity. During LPA’s visits to the facility on 7/16/2021 between 12:10 pm and 5:40 pm, on 9/29/2021 between 11:20 am and 1:20 pm, on 10/20/2022 between 2:00 pm and 3:30 pm, and on 11/20/2023 between 9:30 am and 3:30 pm, LPA did not observe any staff handle residents roughly or act inappropriately. LPA interviewed Administrator about staff performance in 2021, and no staff were subject to disciplinary action based on rough handling or inappropriate interactions with residents. LPA interviewed residents who indicated there were no concerns with the care provided by facility staff. Based on the information obtained, the allegations are deemed Unsubstantiated at this time.

Please continue to 9099-C, Pg 3.

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

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20210709080012
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: ALEXANDER GARDENS
FACILITY NUMBER: 425801995
VISIT DATE: 12/20/2023
NARRATIVE
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On the allegation: Resident is not accorded dignity in relationships with staff. It was alleged that facility staff made a resident who was not incontinent wear diapers because they could not respond fast enough to assist them to the restroom due to a lack of staffing. It was also alleged that on one occasion a staff refused to help a resident to the restroom. R1’s physician’s report dated 5/17/2021 does not indicate any bladder or bowel impairment. However, R1’s preadmission appraisal dated 6/2/2021 indicates R1 needs prompting to toilet regularly and is “usually” not incontinent. R1’s appraisal, needs and services plan indicates R1 needs assistance toileting and needs assistance with products such as briefs and pulls ups. Staff interviewed stated they were not aware of any incidents where residents’ personal rights were violated. Multiple staff indicated if they witnessed something inappropriate, they would not hesitate to call the other staff out or escalate the issue. Staff indicated Resident 1 (R1) was incontinent for the most part, and therefore it was appropriate that R1 to wear diapers. Staff indicated R1 always wore a pull up in case they had an accident, but often wore briefs due to their needs. R1’s admission agreement has an addendum indicating incontinent services and supplies were added to their fee starting 7/1/2021. Staff stated R1 improved due to physical therapy. Staff stated they never heard R1 complain about staff not treating them with dignity. Based on the information obtained, the allegations are deemed Unsubstantiated at this time.

On the allegation: Facility failed to safeguard belongings. It was alleged that the remote control to a resident’s mechanical bed was missing, and reporting party believed it could have been stolen by a staff. Staff stated residents have the inventory form for their personal belongings. Staff stated sometimes residents have lost hearing aids in the past. Staff stated the family is notified as soon as they find out something is missing. Families are told up front to limit expensive items brought into the facility. The facility has replaced missing items before, such as pajamas or pants, and have been offered reimbursement or credit on their fees. LPA reviewed R1’s Resident Personal Property and Valuables form signed by R1’s responsible party. The form is crossed out and “N/A” is written in the area to list personal property/valuables entrusted to the facility. Based on the information obtained, the allegations are deemed Unsubstantiated at this time.

Exit interview conducted. Copy of report issued at the time of the visit.

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

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6