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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561704150
Report Date: 02/01/2022
Date Signed: 02/01/2022 11:15:31 AM



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
07/01/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210701133454
FACILITY NAME:THOUSAND OAKS HOME CARE IIFACILITY NUMBER:
561704150
ADMINISTRATOR:ARNALDO LEGASPIFACILITY TYPE:
740
ADDRESS:9 W. SIDLEE ST.TELEPHONE:
(805) 496-1433
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:0CENSUS: 0DATE:
02/01/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Raymond CesarTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff neglect resulting in resident developing a stage three pressure injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to issue findings for the above allegation. The LPA met with Licensee Representative and explained the reason for the visit. There was a change of ownership, and this facility closed on 10/01/2021. The LPA delivered the findings to the staff Raymond Cesar at the facility titled 9 West Sidlee LLC (565850195). The LPA spoke with Licensee Representative Gilliana Sherman over the phone and informed them of the findings.

On 07/01/2021, the Department received a complaint alleging that due to staff neglect, Resident #1 (R1) developed a stage three pressure injury. The complaint was referred to the Community Care Licensing Investigation's Branch (IB) and it was assigned to Investigator Tiffany Brunelli. On 07/02/2021 between 9:30 a.m. – 11:10 a.m., the LPA interviewed staff, toured the facility, and collected documents. Investigator Brunelli interviewed facility staff on 7/29/2021 at 1:10 p.m., 1:30 p.m. and 1:40 p.m.; interviewed R1’s family members on 10/18/2021 at 3:20 p.m. and 3:30 p.m.; interviewed hospital staff on 11/9/2021 at 11:40 a.m.; interviewed home health staff on 11/5/2021 at 11:50 a.m.; and, reviewed home health and hospital records on 10/28/2021.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
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 3
Control Number 29-AS-20210701133454
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: THOUSAND OAKS HOME CARE II
FACILITY NUMBER: 561704150
VISIT DATE: 02/01/2022
NARRATIVE
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Initial records review revealed that R1 moved into the facility on 12/2/2020 after suffering a fall in their home, resulting in a fracture and subsequent hip surgery. Records review revealed that R1 was discharged with an order for home health due to the hip surgery. R1 was initially noted as having a stage one pressure injury of the coccyx, yet it healed on 12/25/2020. Home health was discharged soon after the coccyx wound healed.

On 3/31/2021, R1 was taken to the doctor’s office, and caregivers reported that R1 had a wound on their upper back (between the shoulder blades) for ‘the last few months’, and although it was healed, it appeared to have been scrapped. After a physical exam, home health was ordered, and the wound was diagnosed as a stage two pressure injury. There was inconsistent information as to how R1 sustained the wound; staff believed that the source of the wound was due to an incident where R1 reportedly attempted to climb over bed-rails and fell out of bed, whereas other staff claimed that R1 frequently turned themselves in bed, causing the wound. Interviews conducted with facility staff and home health staff revealed that R1 utilized an air mattress for the bed and gel cushions while in a wheelchair to prevent pressure injuries.

On 05/13/2021 during a visit with home health, R1 was noted to have low blood pressure and appeared pale. On 05/13/2021, R1 was admitted to the hospital for treatment of seizures, sepsis, and a urinary tract infection. There, it was discovered that R1's wound on their upper back was staged as a stage three healing pressure injury. R1 was admitted to a skilled nursing facility for wound care. R1 was discharged back to the facility with home health for wound care on 6/13/2021 after the wound was noted as ‘superficial’. Home health was ordered, and between 6/13/2021 and 6/26/2021, home health provided wound care at least two times a week. During those visits, the wound on R1’s upper back was regularly diagnosed by the home health nurse as a stage two pressure injury. Notably, home health observed the wound on 6/26/2021, and the wound was noted as shrinking in size, improving, and as a stage two pressure injury. On 6/28/2021, R1 was admitted to the hospital for an altered mental status and an acute UTI. In addition, the wound on R1’s upper back was staged as a stage three pressure injury. R1 did not return to the facility.

Later in the investigation, an interview was conducted with the treating hospital wound continence ostomy nurse (WCON), whom confirmed that they had actually seen R1 on 10/30/2020, prior to R1 being admitted to this facility. Record review and interview revealed that on 10/30/2020, R1 was diagnosed with a traumatic stage three pressure injury on their upper back.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210701133454
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: THOUSAND OAKS HOME CARE II
FACILITY NUMBER: 561704150
VISIT DATE: 02/01/2022
NARRATIVE
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The nurse believed that it would always be diagnosed as a stage three injury or a healing stage three pressure injury. Photos of the pressure injury from 10/30/2020 were compared to the photos of the pressure injury observed on 5/13/2021 and the nurse claimed that the injuries appeared to be the same. The nurse felt that regardless of the remedies in place, it was unlikely for the wound to fully heal as R1 was diagnosed with numerous co-morbidities. Furthermore, the pressure injury was chronic and not infected, the nurse did not see the pressure injury as a sign of neglect or lack of care.

Lastly, an interview with the home health nurse that provided wound care for R1 twice a week claimed that the pressure injury on R1’s upper back was observed as a stage two pressure injury prior to R1 being hospitalized. The nurse claimed that the facility staff complied with the home health orders and did not see any signs or symptoms of neglect or lack of care when R1 was in the facility. As an appropriately skilled professional, the home health nurse regularly observed the wound, and did not corroborate claims that the facility retained R1 with a stage three pressure injury.

Based on the investigation, there is insufficient evidence to support the claim that due to neglect, R1 developed a stage three pressure injury while in care. Interviews and records review noted that R1 had a stage three pressure injury on their upper back prior to being admitted to the facility, yet it is alleged that it had healed prior to being admitted to the facility. The facility ensured that R1 had appropriate wound care and followed all orders as provided by home health. The facility regularly checked in with home health, whom deemed the wound on R1’s upper back as a stage two pressure injury. The facility staff took appropriate action and would send R1 to the hospital as needed. The facility believed that the pressure injury on R1’s upper back was a stage two pressure injury whilst retaining R1. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3