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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703573
Report Date: 07/30/2024
Date Signed: 07/31/2024 12:55:41 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-20240119073807
FACILITY NAME:ELMS RESIDENTIAL CAREFACILITY NUMBER:
561703573
ADMINISTRATOR:HIGGINS, FE LILIA 98FACILITY TYPE:
740
ADDRESS:67 EAST BARNETTTELEPHONE:
(805) 643-2176
CITY:VENTURASTATE: CAZIP CODE:
93001
CAPACITY:54CENSUS: 42DATE:
07/30/2024
UNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Irina Zendeja, Administrator AssistantTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not keep the facility free of bedbugs
Staff did not provide emergency personnel resident records
Staff did not keep the facility clean and sanitary
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.

Regarding allegation “Staff did not keep the facility free of bedbugs” and “Staff did not keep the facility clean and sanitary”.

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. The interview with residents revealed the following: eight (8) out of eight (8) residents expressed that they have experienced bedbugs in their room in the past and continue to have issues with bed bugs. Residents confirmed that an exterminator comes around every month or so to spray; however, the problem still exists. (Continue to LIC9099c).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (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 6
Control Number 29-AS-20240119073807
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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LPA observed resident rooms to be unkept, with sticky floors, trash full in resident rooms and bedding unclean and unsanitary. Administrator acknowledged that they had a bedbug problem, however the bedbug problem is confined to a couple of rooms and all measures are taken immediately to address the bedbug situation, by replacing mattresses, pillows and calling the exterminator to spray the rooms. Administrator stated that the resident rooms are cleaned at least once a week. According to administrator the resident rooms which were observed unkept refused housekeeping. Information gathered from a credible witness confirmed a residents’ bedroom was observed on 01/17/2024, full of insects such as bed bugs, dirty with trash everywhere and numerous trash bags sitting next to the resident’s room door. Based on the above information gathered, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the allegation “Staff did not keep the facility free of bedbugs” and “Staff did not keep the facility clean and sanitary” are deemed SUBSTANTIATED at this time.

Regarding allegation “Staff did not provide emergency personnel resident records”. It was reported that on 01/17/2024, emergency personnel was summons to the facility and staff could not provide any information or records for Resident #1 (R1). Interview with administrator on 01/22/2024, confirmed that at the time of the incident on 01/17/2024, staff did not have access to the resident records; therefore, could not provide to emergency personnel. Based on the above information gathered, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the allegation “Staff did not keep the facility free of bedbugs” 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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (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 6
Control Number 29-AS-20240119073807
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 B
08/06/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by
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Administrator assistant stated that she will provide documentation by 8/6/24 from pest control company indicating that they have treated the facility and develop and maintain a cleaning plan/schedule; also submit a written plan on how they will prevent future incidents from reoccurring.
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Based on interviews, the licensee did not ensure that the facility remained free of bed bugs and maintain cleanliness of facility common areas, resident rooms and bathrooms. This posed a potential safety and health risk to resident’s in care.
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Type B
08/06/2024
Section Cited
CCR
87506(a)
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Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement was not met as evidence by
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Administrator assistant will submit a plan how you will ensure all resident records are mainted upto date and available/accessible to staff to provide to emergency personnel. Submit to CCL by due date.
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Based on observation and interview with credible witness licensee did not comply with this section. R1's records were not available/accessible to staff therefore records were not provided to emergency personnel. This posed a potential safety and health risk to resident’s 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (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: 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
01/19/2024 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20240119073807

FACILITY NAME:ELMS RESIDENTIAL CAREFACILITY NUMBER:
561703573
ADMINISTRATOR:HIGGINS, FE LILIA 98FACILITY TYPE:
740
ADDRESS:67 EAST BARNETTTELEPHONE:
(805) 643-2176
CITY:VENTURASTATE: CAZIP CODE:
93001
CAPACITY:54CENSUS: 42DATE:
07/30/2024
UNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Irina Zendeja, Administrator AssistantTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Questionable Death
Staff did not post the facility license in a prominent location in the facility.
Insufficient staffing
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 of “Questionable death” of a resident #1 (R1). It was reported that R1 was deceased upon emergency personnel arrival and that staff did not have any information for this resident. It was also reported that staff could not recall the last time they saw resident alive.

On 01/19/2024, this case was referred to the Investigations Branch (IB) and assigned to Investigator Olivia Spindola. On 01/22/2024, LPA Chochian conducted the initial complaint visit. During the initial visit, at approximately 3:25pm, LPA toured the facility with staff. At approximately 5:30pm, LPA reviewed records and obtained copies of available records pertinent to the allegations. On 01/22/2024, 01/24/2024, 01/25/2024, 01/31/2024, 02/14/2024, 02/17/2024 and 02/27/2024, Investigator Spindola conducted (cont..)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (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: 4 of 6
Control Number 29-AS-20240119073807
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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 interview with facility staff, witnesses, and residents; also records from the Ventura Police Department, Ventura Fire Department who responded to the 911 call regarding resident’s death, and Ventura County Medical Examiner (VCME) autopsy reports were also obtained and reviewed.

Information gathered during the course of the investigation revealed that resident died approximately one (1) day prior to Staff #1 (S1) finding R1 unresponsive in R1’s room. R1 had not seen a doctor since R1’s Conservatorship ended in 2011. According to the staff, R1 would only come out of the room to retrieve lunch and sometimes dinner. The staff also indicated that R1 was known to carry a broom in a threatening manner to prevent anyone from making any contact with R1. Staff reported that R1 would not allow them to enter room to clean it or provide any other type of assistance. Interviews revealed that R1 was responsible for self, did not receive any care services from facility staff and had not seen a doctor since 2011; therefore, R1’s health condition was unknown. The VCME determined R1s cause of death to be arteriosclerotic cardiovascular disease, and the manner of death was noted as natural causes. Based on the autopsy report, staff, and witnesses’ statements it was concluded that although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation of “Questionable death” is deemed UNSUBSTANTAITED at this time.

Regarding allegation “Staff did not post the facility license in a prominent location in the facility.” It was reported that the facility license was not posted in a prominent location where it could be seen. LPA conducted a tour of the facility on 01/22/2024 with administrator and the facility license was observed posted in an area which was identified by administrator as the entrance of the facility were all required postings are placed. According to administrator the facility license was posted on the wall since licensure and was never removed. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not post the facility license in a prominent location in the facility” is deemed UNSUBSTANTIATED at this time.

Regarding Allegation “Insufficient staffing.” It was original reported that on 01/17/2024, there was only one staff member present during the emergency personnel visit however later it was said to be that two (2) staff were observed at the facility with 43 residents. According to reporting party the residents at this facility are not provided appropriate care and supervision due to insufficient staffing. On 01/22/2024, allegation was discussed with administrator and staff. In addition, random residents were interviewed. All residents interviewed stated there is sufficient staffing to meet their needs. (Continue to LIC9099c).
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (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: 5 of 6
Control Number 29-AS-20240119073807
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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 Residents expressed that they are independent and don’t need assistance from staff. Residents confirmed that there is always staff and/or the administrator at the facility to assist if needed. Residents interviewed stated that they only need assists with meals being prepared, laundry services and medication assistance. Administrator Fe stated that she is always present at the facility with at least two to three other staff. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Insufficient staffing” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Appeal rights and a copy of the report was provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (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: 6 of 6