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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 03/03/2023
Date Signed: 03/03/2023 04:39:40 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
04/14/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210414083514
FACILITY NAME:TREACY VILLAFACILITY NUMBER:
561703345
ADMINISTRATOR:EVANGELINE MICHAYLUKFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA RDTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:0CENSUS: 0DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Patrick Treacy, Former Licensee Via Email and mailTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff did not follow residents care plan causing residents pressure injury to become unstageable.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson delivered final findings for the above allegations via email and certified mail, due to the facility closed 06/22/2021 due to a change of ownership.

On the allegation: Staff did not follow residents care plan causing residents pressure injury to become unstageable. Concerns were that staff did not follow resident #1 (R1)’s care plan causing residents pressure injury to become unstageable as staff were not putting on R1’s heel protector or turning R1 in bed properly.

On 4/15/21 starting at 8:07 pm interviews were conducted with Hospice nurse, staff, on 12/8/22 starting at 8:39 am interviews were conducted with staff and resident family members, and on 12/14/22 starting at 1:15 pm interviews were conducted with staff and resident family members. A review of R1’s records on 12/8/22 starting at 10:05 am revealed that on R1 was prescribed a padded heel protector on 1/13/21 by the Hospice nurse. Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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 7
Control Number 29-AS-20210414083514
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: TREACY VILLA
FACILITY NUMBER: 561703345
VISIT DATE: 03/03/2023
NARRATIVE
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One staff stated sometimes staff would remove R1’s heel protector and not put it back on, and R1 sometimes had it on but sometimes did not. R1 needed to be repositioned every 2 hours, and staff repositioned R1 every 2 to 2 ½ hours. Staff stated there was no repositioning log to confirm R1 was repositioned timely. Hospice nurse confirmed R1’s deep tissue injury turned into an unstageable injury, and believed it was due to staff not consistently using the heel protectors. LPA reviewed R1’s hospice care plan from 2020, which does not state in writing staff needed to ensure R1 was wearing the padded heel protectors. LPA reviewed Hospice Notes that do not indicate written instructions about how to use the padded heel protector, even though there is an order for it. Based on the information obtained during the investigation, the allegation staff did not follow residents care plan causing residents pressure injury to become unstageable is substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Today's reports and appeals rights were mailed via certified mail and regular mail to the former Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20210414083514
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: TREACY VILLA
FACILITY NUMBER: 561703345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2023
Section Cited
CCR
87464(f)(1)(c)
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87464(f)(1)(c) Basic services. "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
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Facility Closed.
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Assistance…This requirement is not met as evidenced by:
Based on interviews and record review, the licensee did not comply with the section cited above as staff did not follow Hospice orders and R1’s heel injury became unstageable which posed an immediate
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health and safety risk to persons 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: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
04/14/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210414083514

FACILITY NAME:TREACY VILLAFACILITY NUMBER:
561703345
ADMINISTRATOR:EVANGELINE MICHAYLUKFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA RDTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:0CENSUS: 0DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Patrick Treacy, Former Licensee Via Email and mailTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility staff failed to provide an appropriate level of supervision which resulted in Resident #1’s death.
Facility staff failed to seek timely medical attention for Resident #1 during a medical emergency.
Staff did not properly supervise resident during mealtime.
Staff did not follow physician's orders for medications.
Staff locked and barricaded resident in bedroom.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson delivered final findings for the above allegations via email and certified mail, due to the facility closed 06/22/2021 due to a change of ownership.

On 04/14/2021, the Department received a complaint that alleged on 04/13/2021 at 4:15pm, staff called R1’s hospice agency to report that R1 was turning blue, unresponsive and choking on food R1 had taken off another resident’s plate in the dining room. The staff did not know if they should call 911 or perform CPR. The hospice agency instructed them that R1 was full code and to call 911 and perform CPR. The complainant also reported that there was only one staff supervising the residents in the dining room. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Douglas Real.

On 04/15/2021, from 10:50am to 3:30pm, Licensing Program Analysts (LPAs) JoAnn Rosales and Ashley Morgan conducted an unannounced initial complaint visit for the above allegations. Contined on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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 7
Control Number 29-AS-20210414083514
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: TREACY VILLA
FACILITY NUMBER: 561703345
VISIT DATE: 03/03/2023
NARRATIVE
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The LPAs determined further investigation was required. On 4/15/21 starting at 12:05 pm, LPA conducted interviews with staff, on 12/8/22 starting at 8:39 am interviews were conducted with staff and resident family members, and on 12/14/22 starting at 1:20 pm interviews were conducted with staff and resident family members.

On 06/07/2021, Investigator Real conducted interviews with the facility Administrator, staff, and attempted to interview Resident #2 (R2); on 07/13/2021, with hospice staff and former facility staff; and on 07/28/2021, with hospice staff. Additionally, the investigator reviewed the Ventura County Medical Examiner’s Office death investigation report for R1, and facility file documents related to R1.

A review of R1’s physician report indicated R1’s diagnoses as dementia, chronic atrial fibrillation and urinary tract infection. R1 was listed as confused/disoriented, able to follow instructions, and able to communicate needs. R1 was listed as able to feed self and was on a special diet. R1 needed assistance for bathing, dressing, toileting, and managing cash resources. R1 was not able to administer their own medications. R1 was listed as non-ambulatory due to both mental and physical reasons. There was no date listed on the report. The Appraisal/Needs and Services Plan form was dated 12/21/2020 and identified R1 as partially independent but unable to stand on their own. R1 needed assistance with activities of daily living except eating. R1 was able to use their upper body more than legs. R1 could follow commands but needed assistance with standing.

On 07/19/2021, Investigator Real received a copy of the Ventura County Medical Examiner’s Office death investigation report for R1. The investigation included interviews with facility staff, hospice staff and a review of the video footage of the facility dining room showing the events leading up to R1 becoming unresponsive. The interviews revealed that facility Staff #1 (S1) performed the Heimlich maneuver on R1 after finding R1 unresponsive. Facility staff contacted R1’s hospice agency and were notified R1 was a full code at which point 911 was initiated. CPR was performed until paramedics arrived. Paramedics attempted lifesaving measures with R1 for approximately 20 minutes. R1’s resident representatives declined additional life saving measures and R1 was pronounced dead at 4:53pm. The 04/13/2021 video footage reviewed revealed that R1 was seated at a table with another resident and R1 did not grab any food from the other resident. R1 was served pureed food around 4:04pm and ate their food until about 4:06pm. R1 continued to move their head and hands until approximately 4:11pm. At approximately 4:12pm, a male caregiver (S1) approached R1 and performed the Heimlich maneuver. Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20210414083514
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: TREACY VILLA
FACILITY NUMBER: 561703345
VISIT DATE: 03/03/2023
NARRATIVE
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R1 did not exhibit any signs of choking. Based on his investigation, the Medical Examiner Investigator concluded R1’s death appeared to be due to natural disease processes. No abuse or neglect concerns were noted in the report.

On the allegation “Facility staff failed to provide an appropriate level of supervision which resulted in Resident #’1’s death.” Interviews revealed R1 had a medical emergency during dinner and S1 immediately attempted life saving measures. The facility staff contacted R1’s hospice agency and were notified R1 was a full code at which point 911 was called and R1 was moved to their room and CPR initiated. The facility staff denied the allegation and reported immediately caring for R1 when the medical emergency was observed. The care included performing the Heimlich maneuver as well as CPR. The hospice agency confirmed the facility staff called them and reported the medical emergency. The facility staff were not aware R1 was a full code (attempt life saving measures) and had to be informed over the phone during the medical emergency. The Ventura County Medical Examiner’s office investigated R1’s death and concluded R1 passed away due to natural causes and no abuse or neglect concerns were noted. The information and evidence obtained did not sufficiently support the allegation, therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation “Facility staff failed to seek timely medical attention for Resident #1 during a medical emergency.” The investigation revealed the facility staff acted appropriately by attempting life saving measures which included the Heimlich maneuver after observing R1 in an unresponsive state during dinner. During the incident facility staff contacted R1’s hospice agency, called 911 and performed CPR until paramedics arrived. The information and evidence obtained did not sufficiently support the allegation, therefore the case is deemed Unsubstantiated at this time.

On the allegation “Staff did not properly supervise resident during mealtime.” Interviews revealed there were at least two facility staff in the dining room on the date of 4/13/2021. Facility documents related to R1 did not indicate R1 required assistance or supervision while eating. The information and evidence obtained did not sufficiently support the allegation, therefore the case is deemed Unsubstantiated at this time.

Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20210414083514
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: TREACY VILLA
FACILITY NUMBER: 561703345
VISIT DATE: 03/03/2023
NARRATIVE
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On the allegation “Staff did not follow physician's orders for medications.” Interviews revealed that staff and family members are not aware of any staff not following physician’s orders for medications. Staff denied not following physicians orders for resident medications. Addition medication documents were unable to reviewed due to the facility being closed. Based on the information obtained during the investigation, the allegation staff did not follow physician's orders for medications is unsubstantiated at this time.

On the allegation “Staff locked and barricaded resident in bedroom.” The complainant’s concern was that staff locked and barricaded a resident in their bedroom when they tested positive for COVID-19, to prevent them from wandering the facility due to their dementia. Interviews revealed that staff and resident family members did not observe any staff locking or barricading residents in their bedrooms. Staff denied locking or barricading residents in their bedrooms. Based on the information obtained during the investigation, the allegation staff locked and barricaded resident in bedroom is unsubstantiated at this time.

Today's reports were mailed via certified mail and regular mail to the former Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7