565800182-5-23-2023-29-AS-DPEA-CSCLV9-20230531090509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800182
Report Date: 05/23/2023
Date Signed: 05/23/2023 03:52:37 PM

Unsubstantiated

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
05/04/2023 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20230504142222

FACILITY NAME:	ST. PAUL'S R.C.F.E.		FACILITY NUMBER:	565800182
ADMINISTRATOR:	MALARI MARILOU		FACILITY TYPE:	740
ADDRESS:	2292 GODDARD AVE		TELEPHONE:	(805) 581-9457
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	5	CENSUS: 4	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	02:43 PM
MET WITH:	Marilou Malari		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Resident sustained unknown bruising while in care of facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 05/09/2023 by LPA Arroyo. On today’s visit, LPA Arroyo met with Administrator, Marilou Malari and the reason for the visit was explained. Entrance interview.

During the initial visit on 05/09/2023, LPA Arroyo toured the facility to ensure there are no health and safety concerns at 1:22pm, conducted interviews with the Administrator, two staff, and one resident between 1:25pm and 1:42pm, and conducted a resident file review and obtained copies of resident records and other pertinent documents at 2:00pm. The LPA also conducted a telephonic interview with resident’s family member on 05/15/2023 at 2:53pm.

Report Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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-20230504142222

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: ST. PAUL'S R.C.F.E.	FACILITY NUMBER: 565800182
	VISIT DATE: 05/23/2023

NARRATIVE

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Report Continued from LIC 9099...

It was alleged that resident sustained unknown bruising while in care of facility. It was reported that during a visit, bruises were reported being seen on Resident #1’s (R1’s) armpit. Review of documents revealed that on R1’s Physician’s Report dated 04/27/2023 indicates R1 is total care. R1 requires assistance with all activities of daily living (ADL’s) such as bathing, grooming/dressing, feeding, administration of medication, and all incontinence needs. Interviews conducted with staff revealed R1 is constantly being transferred as R1’s body has become stiff and cannot move on their own. Additionally, staff stated R1 recently had a blister on their armpit, which they took photographs and reported to Community Care Licensing (CCL), Home Health (HH), and R1’s Primary Care Physician (PCP) and family. Furthermore, interviews with R1’s family revealed they had visited R1 at the facility and noticed the marks on R1’s armpit; however, denied seeing any type of bruising on R1. R1’s family stated the facility staff has been good to R1 and has never neglected R1 at any time. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation “Resident sustained unknown bruising while in care of facility”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview. A copy of the report was issued to the Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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