561703573-7-31-2024-29-AS-DPEA-D7PVKZ-20240731163111

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 561703573
Report Date: 07/30/2024
Date Signed: 07/31/2024 04:27:37 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
01/19/2024 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20240119160628

FACILITY NAME:	ELMS RESIDENTIAL CARE		FACILITY NUMBER:	561703573
ADMINISTRATOR:	HIGGINS, FE LILIA 98		FACILITY TYPE:	740
ADDRESS:	67 EAST BARNETT		TELEPHONE:	(805) 643-2176
CITY:	VENTURA	STATE: CA	ZIP CODE:	93001
CAPACITY:	54	CENSUS: 42	DATE:	07/30/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Irina Zendeja, Administrator Assistant		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility staff did not seek medical attention for resident.
Facility staff did not notify resident's responsible person of injury to resident.
Facility staff are not safeguarding confidential records.
Facility staff do not clean bedroom floors.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with Irina Zendeja. The reason for the visit was explained.

On 01/19/2024, Community Care Licensing Division received an allegation that “Facility staff did not seek medical attention for resident”. Per the Reporting Party (RP) it was discovered on 12/27/2023, that Resident #1 (R1) had injured R1s right foot. R1 was taken to the Emergency Room (ER), where it was discovered that R1 had broken R1’s leg in multiple places. The injury was noted to be old given the bruising.

On 01/22/2024, this case was referred to the Investigations Branch and assigned to Investigator Veronica Padilla. On 01/22/2024, LPA Chochian conducted the initial complaint visit. LPA met with staff Marysol Magallanas and later with Administrator Fe Higgins. During the initial visit, at approximately 3:45pm, LPA toured the facility with staff. At approximately 5:30pm, LPA reviewed records and obtained copies of pertinent records. (Continue to 9099c)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

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-20240119160628

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: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 07/30/2024

NARRATIVE

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On 02/14/2024 at 10am, Investigator Padilla conducted interview with R1 and a potential witness. On 02/22/2024, Investigator Padilla obtained additional medical records from the Ventura County Medical Center for R1. On 02/28/2024 at 10:30am, Investigator Padilla conducted a subsequent visit to the facility, a physical plan tour was conducted, and facility staff were interviewed. Furthermore, on 05/07/2024 at 8:25am, Investigator Padilla interviewed R1’s case manager; and on 05/17/2024 at 1:15pm an interview was conducted with Detective Hain from the Ventura Police Department.

The investigation revealed that R1 had an unwitnessed fall (date unknown) which resulted in multiple fractures of left foot, and staff failed to seek timely medical attention. On 12/27/23, R1’s case manager observed R1 limping and in pain. R1 was taken to the emergency room and physician reported that R1 had a subacute fracture involving the distal second, third, and fourth metatarsals and possibly the fifth. Also noted that R1 had callus formation, indicating that they are probably at least four weeks old. Staff #1 (S1) admitted to seeing R1 walking around the facility without wearing shoes during the first week of December, and R1 told staff that foot hurt. Staff did not address R1’s change in condition and asked other staff if it was normal for R1 to walk around the facility without shoes on and limping. Interviews and records review revealed that no one at the facility assessed R1’s foot, nor did any facility staff member ask R1 why R1 was limping or not wearing shoes. The staff additionally did not ask R1 to put shoes on, even though permitting R1 to walk shoeless posed a potential safety concern. R1's last physician’s report states that R1 has schizophrenia and mild cognitive impairment with occasional confusion but an ability to follow instructions. R1’s residential appraisal states that R1 has also been experiencing some memory problems and needs assistance with health and medical care. Interviews conducted and records reviewed revealed that R1’s Basic Services, sections B numbers two and three, were not met because the facility failed to observe R1’s physical condition and notify the resident’s physician and other appropriate person(s)/agencies of the resident’s change in condition and/or needs. Based on the interviews and records reviewed, there is sufficient evidence to support the allegation or that a violation occurred; therefore, the allegation of “Facility staff did not seek medical attention for resident.” is deemed Substantiated at this time.

Regarding allegation “Facility staff did not notify resident's responsible person of injury to resident.”:
It was reported that R1’s responsible person was never informed of R1’s foot injury incident. On 12/27/2023, R1’s case manager noticed R1 was limping and in pain. R1 was taken to the emergency room and there it was revealed that R1’s left foot had a subacute fracture involving the distal second, third, and fourth metatarsals and possibly the fifth. (Continue to 9099c)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20240119160628

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: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 07/30/2024

NARRATIVE

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Also noted that R1 had callus formation, indicating that they are probably at least four weeks old. Interviews conducted with staff on 1/22/2024 and 02/28/2024 confirmed that facility staff observed resident limping and walking around shoeless and did not address the issues and did not notify R1’s responsible person. Based on the above information gathered, there is sufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility staff did not notify resident’s responsible person of injury to resident” is deemed Substantiated this time.

Regarding Allegation “Facility staff are not safeguarding confidential records.”: It as reported that obtaining information from the facility is difficult because there is no office staff. A potential witness reported that they were allowed to enter the office space where resident records are kept by administrator’s daughter and was able to see other residents’ confidential records and was given access to R1’s medication administration record. On 01/22/2024, allegation was discussed with administrator. Administrator reported that she was not aware of this incident since no one reported to her. Based on the above information gathered, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the allegation “Facility staff are not safeguarding confidential records” is deemed Substantiated at this time.

Regarding Allegation “Facility staff do not clean bedroom floors.” On 1/22/2024, at approximately 3:25pm, LPA and the administrator conducted a tour of the facility and checked facility common areas and random resident rooms. The LPA also conducted random resident interviews during the resident room tours from approximately 3:30p.m. to 5:30 p.m. The LPA conducted an inspection of eight (8) resident rooms and spoke with residents in each room. Five out of eight residents expressed that their room is never cleaned when needed. LPA observed all eight resident rooms to be unkept, with sticky floors, trash full in resident rooms and bedding unclean and unsanitary. Administrator stated that the resident rooms are cleaned at least once a week. According to administrator the residents sometime refuse housekeeping, so staff are unable to go in to clean. Information was provided by credible witnesses who confirmed that the facility is overall observed unkept and residents’ bedrooms were observed on several incidents with clutter, dusty, and dirty sticky floors. Based on the above information gathered, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the allegation “Facility staff do not clean bedroom floors” is deemed Substantiated at this time.
The following deficiencies were cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240119160628

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: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/31/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident:The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.... This requirement was not met as evidence by	1 2 3 4 5 6 7	Administrator assistant agreed to develope and submit a plan how they will ensure medical attention for residents obtained timely; and plan to ensure residents responsible persons are notifyed of any and all resident incident/injuries.
	8 9 10 11 12 13 14	Based on interviews, and records review Licensee/Administrator did not obtain timely medical attention for R1 and did not report to the responsible person for R1 when it was noticed that R1 was limping due to pain (multiple fractures) of the left foot.	8 9 10 11 12 13 14
Type B 08/06/2024 Section Cited CCR 87506	1 2 3 4 5 6 7	Resident records - (c) All information and records obtained from or regarding residents shall be confidential. This requirement was not met as evidence by: Based on interviews staff had resident records accessible to others and did not maintain records cofidential.	1 2 3 4 5 6 7	Administrator assistant stated that resident records are kept in the closet next office which is always kept locked. Submit a plan on how you will ensure resident records are kept confidential at all times.
Type B 08/06/2024 Section Cited CCR 87303	1 2 3 4 5 6 7	Maintenance and Operation:(a)..facility shall be clean, safe, sanitary and in good repair at all times...(1) Floor surfaces..... shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidence by: Based on observation, Licensee did not maintain facilility common areas and resident rooms (6,10,14,13,27)	1 2 3 4 5 6 7	Administrator assistant agreed to develope and submit a plan to ensure facility is maintained clean and sanitary at all times.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4