565800134-7-30-2021-29-AS-JAPL-C5QN6Q-20210809101128

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800134
Report Date: 07/30/2021
Date Signed: 07/30/2021 03:37:51 PM

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
07/22/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20210722160230

FACILITY NAME:	THOUSAND OAKS HOMECARE III		FACILITY NUMBER:	565800134
ADMINISTRATOR:	LILIAN Z. CHUA		FACILITY TYPE:	740
ADDRESS:	143 WEST SIDLEE STREET		TELEPHONE:	(805) 494-8860
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	07/30/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Gilliana Sherman and Jovy Sarreal		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident sustained an injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct an initial complaint investigation. The LPA met with staff Gilliana Sherman and Vea Vicedo and explained the reason for the visit. The LPA also spoke with Administrator Jovy Sarreal over the phone and explained the reason for the visit.

During today's visit, the LPA conducted a tour at 1:50 p.m., reviewed documents at 2:00 p.m., and interviewed staff at 2:08 p.m., 2:11 p.m., 2:17 p.m., and 2:27 p.m. In addition, the LPA conducted interviews with home health representatives on 7/27/2021 at 2:40 p.m. and 7/29/2021 at 3:10 p.m.

Regarding the allegation, it was alleged that Resident #1 (R1) sustained an unexplained injury while in care. Interviews conducted and records review revealed that on approximately 7/12/2021, R1 sustained a bruise under their right eye. Interviews confirmed that Staff #1 (S1) primarily provides care for R1 and noted that while changing R1, R1 was rolled on their side to be cleaned. Upon transferring R1, S1 observed R1 with the bruise under their eye. S1 does not know how the bruise appeared on R1.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210722160230

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 HOMECARE III	FACILITY NUMBER: 565800134
	VISIT DATE: 07/30/2021

NARRATIVE

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During today's visit, the LPA observed R1's bedroom and R1 was laying in bed. The LPA observed that R1 has two side rails. S1 and staff were unable to communicate if R1 accidentally hit something (ie. side rail) while being turned over, but noted the presence of the bruise when R1 was turned. Interviews further noted that R1 did have skin integrity issues and was taking aspirin, yet were still unable to confirm how R1 sustained the bruise. Additional interviews confirmed that S1 notified staff, whom then notified the Administrator, yet the facility did not submit an Unusual Incident Report to Community Care Licensing documenting the occurrence of the bruise.

Based on the information obtained, there is sufficient evidence to support the claim that the resident sustained a bruise while in care. This allegation is deemed Substantiated at this time.

Deficiencies cited on 9099-D. Exit interview conducted. A copy of the report and appeal rights are provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210722160230

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 HOMECARE III	FACILITY NUMBER: 565800134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/03/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services. Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Submit a Statement of Understanding, noting measures the staff regarding the prevention of residents sustaining bruises. Submit the Plan of Action to CCL by 8/3/2021.
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited above, as R1 sustained an bruise of an unknown origin, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	2. Host an in-service training regarding appropriate transferring methods and working with residents with skin integrity issues. Submit sign-in sheet and any training materials. Training must be done by 8/16/2021.
Type B 08/06/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211(a)(1)(D). Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including: Any incident which threatens the welfare, safety or health of any resident This requirement is not met as evidenced by:	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	Based on observation and interview, the licensee did not comply with the section cited above, as the facility did not submit an unusual incident report regarding the presence of the bruise, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	The Administrator agreed to do the following: 1. Submit an incident report from the 7/12/2021 occurence of the bruise. Submit incident report by 8/6/2021.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

LIC9099 (FAS) - (06/04)

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