565800417-5-12-2023-29-AS-JAPL-CRVRC7-20230516125353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800417
Report Date: 05/12/2023
Date Signed: 05/12/2023 10:26:33 AM

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
02/25/2022 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20220225161030

FACILITY NAME:	SIMI VALLEY RESIDENTIAL CARE IV		FACILITY NUMBER:	565800417
ADMINISTRATOR:	MARIA MENDEZ		FACILITY TYPE:	740
ADDRESS:	2378 E. KENTFIELD STREET		TELEPHONE:	(805) 583-3182
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 4	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Maria Mendez		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility staff did not wear facemasks around resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to the facility regarding the above noted allegation. LPA met with administrator Maria Mendez and explained the reason for the visit.

On 3/1/2022 at 9:49 a.m., LPA conducted an initial complaint investigation visit to the facility. LPA reviewed and obtained pertinent documents. LPA conducted staff interviews with two staff. On 3/1/2022 at 12:50 p.m., LPA conducted a visit to Adventist Health Simi Valley Hospital. LPA interviewed three hospital staff and resident 1 (R1).

(continued on page 2; 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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 5

Control Number 29-AS-20220225161030

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: SIMI VALLEY RESIDENTIAL CARE IV	FACILITY NUMBER: 565800417
	VISIT DATE: 05/12/2023

NARRATIVE

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(continued from page 1; 9099)

Upon arrival to the facility on 3/1/2022, LPA observed two staff at the facility not wearing facemasks. Both staff put their masks on when LPA pointed out they were not wearing their masks. LPA spoke with the administrator regarding the allegation staff were not wearing masks at the facility. Administrator stated that staff told her they had used the restroom and forgot to put it back on. LPA pointed out that both staff were not wearing masks but working with residents. Based on LPA’s observations, the allegation facility staff failed to wear facemasks around residents is deemed Substantiated at this time.

It is noted that the California Department of Public Health COVID-19 masking requirements ended on 4/3/2023. The Centers for Disease Control may still recommend masks based on local community levels (by county). Administrator is aware she must stay up to date on any requirements which may change based on COVID-19 community levels. She will ensure all staff follow the most current mandates.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20220225161030

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: SIMI VALLEY RESIDENTIAL CARE IV	FACILITY NUMBER: 565800417
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/12/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced	1 2 3 4 5 6 7	During LPA’s visit, the administrator counseled staff regarding wearing masks in the facility at all times. Administrator stated she would ensure staff wears masks when mandated by the government (federal, state, and local authorities).
	8 9 10 11 12 13 14	by: Based on interviews and observation, the licensee did not comply with the section cited above. LPA observed staff working with residents while not wearing facemasks, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
02/25/2022 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20220225161030

FACILITY NAME:	SIMI VALLEY RESIDENTIAL CARE IV		FACILITY NUMBER:	565800417
ADMINISTRATOR:	MARIA MENDEZ		FACILITY TYPE:	740
ADDRESS:	2378 E. KENTFIELD STREET		TELEPHONE:	(805) 583-3182
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 4	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Maria Mendez		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility failed to provide refund
Facility staff failed to follow resident's prescribed diet

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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 5

Control Number 29-AS-20220225161030

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: SIMI VALLEY RESIDENTIAL CARE IV	FACILITY NUMBER: 565800417
	VISIT DATE: 05/12/2023

NARRATIVE

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(continued from 9099-A; page 4)

LPA reviewed R1’s admission agreement. R1 was admitted to the facility in 2015, therefore any preadmission fees are not refundable as R1 resided at the facility longer than three months. R1’s admission agreement stated the scenarios in which the facility would provide a prorated refund: death of resident or facility closure (both are Title 22 requirements), otherwise the facility requires a 30-day notice. R1 left the facility on 2/2/2022 to go to the hospital, R1’s health condition progressed and R1 needed a higher level of care so R1’s representative moved R1’s belongings out of the facility on 2/12/2022. Although R1’s representative did not provide the facility with a 30-day notice, the facility did provide a refund to R1 for 2/12/2022-2/28/2022 on 2/28/2022 which was not required by Title 22. Therefore, the allegation the facility failed to provide a refund is deemed Unsubstantiated at this time.

LPA reviewed R1’s medical documents from R1’s dietician at the facility. The documents state the type of diet R1 was to have. R1 did not have any dietary restrictions, however due to R1’s condition all food must be pureed/soft, and liquids must be thickened. In addition, the facility was to provide R1 with Ensure for between meal snacks. Staff stated R1 was able to eat the pureed diet but must eat slowly and be constantly observed to ensure R1 did not choke on their food. Staff stated they provided R1 with thickened Ensure, however R1 didn’t like the type of Ensure he was sent by his representative and/or the VA.

LPA interviewed R1 at the hospital, R1 indicated facility staff did provide Ensure but R1 didn’t like the Ensure. R1 said they liked living at the facility, staff treated R1 with respect, and R1 liked the pureed/soft food provided at the facility.

LPA interviewed hospital staff to see if they were providing Ensure to R1. Hospital staff explained that due to R1’s condition progressing, R1 could not safely swallow, and they were not able to give anything by mouth at that time.

Based on interviews and records review, the allegation facility staff failed to follow resident's prescribed diet is deemed Unsubstantiated at this time.

Exit interview conducted and a copy of this report issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5