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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800494
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:09:53 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
12/23/2021 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20211223153856
FACILITY NAME:SALLY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
565800494
ADMINISTRATOR:KAYHAN MOJABIFACILITY TYPE:
740
ADDRESS:928 CARISSA COURTTELEPHONE:
(805) 384-8043
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 6DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Sara JacksonTIME COMPLETED:
11:18 AM
ALLEGATION(S):
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R1’s death was due to inadequate care and supervision
Due to facility neglect, Resident #1 (R1) developed Septic Shock
Due to facility neglect, Resident #1 (R1) developed a bowel obstruction
Due to facility neglect, Resident #1 (R1) developed a fecal impaction of unknown etiology

INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kelly Dulek and Teresa Camara conducted an unannounced subsequent complaint visit to deliver findings for the above noted allegations. LPAs met with Facility Designee Sara Jackson and discussed the reason for today’s visit. Entrance interview conducted.

It was alleged that due to facility neglect, R1 developed septic shock, bowel obstruction and fecal impaction of unknown etiology, which ultimately led to the death of R1.

On 04/20/2021, the California Department of Social Services (Department) Community Care Licensing Division (CCLD) received a related complaint (control # 29-AS-20210420140721) alleging R1 passed away due to inadequate care and supervision by facility staff. The complainant’s concern was that R1’s cause of death was indicative of poor care at the facility. On 04/21/2021 at 10:11 a.m., Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced complaint visit and met with Administrator Kayhan
Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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 8
Control Number 29-AS-20211223153856
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: SALLY'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565800494
VISIT DATE: 05/16/2023
NARRATIVE
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Mojabi. LPA Lopez explained the reason for the visit and conducted a brief physical plant tour at 10:20 a.m. while also briefly interviewing the Administrator and Staff #1 (S1). At 10:31 a.m., LPA Lopez reviewed and obtained pertinent facility documents.

On 04/20/2021, the complaint was referred to CCLD’s Investigations Branch (IB), which was accepted and assigned to Investigator Douglas Real on 04/21/2021. Investigator Real conducted interviews on 06/11/2021, 07/09/2021, and 07/27/2021. Interviews were conducted with R1’s court appointed conservator/responsible party, facility staff, Administrator, and facility residents. In addition, Investigator Real reviewed hospital records for R1 on 06/14/2021.

Hospital records reflected that R1 was admitted to the hospital on 02/01/2021 due to lethargy. Diagnostic testing was performed and based on the results, R1 was noted to have very low chances of survival. R1 passed away on 02/02/2021 at the hospital. There were no concerns for abuse or neglect noted in the hospital records. Additionally, an interview with one of the hospital physicians attending to R1 indicated no concerns of abuse or neglect and the physician stated if there were such concerns by any of the medical staff it would have been noted in the medical record. The physician recalled R1 was unable to communicate needs or describe symptoms. Interviews with residents revealed no concerns regarding care and supervision at the facility. None of the residents interviewed experienced or witnessed any abuse or neglect at the facility. Interviews with staff and the Administrator indicated they provided care to R1 for approximately one year. R1’s health declined due to R1’s medical condition. To their recollection, R1 never suffered any accidents or injuries while residing at the facility. They denied the allegation that R1’s death was a result of insufficient care. During another interview, R1’s conservator/responsible party stated they were very happy with the level of care R1 received from facility staff and the communication they provided about R1’s health. R1 was sent to the hospital due to concerns from facility staff about R1’s declining state. Although R1 passed away shortly after being admitted to the hospital, the hospital told the conservator/responsible party that there were no concerns of abuse or neglect by the facility. Based on the above noted investigation, an “unsubstantiated” finding was delivered to the facility on 12/09/2021 by LPA Teresa Camara regarding the allegation that R1’s death was a result of inadequate care and supervision by facility staff.

On 12/23/2021, the Department received a request to reopen the investigation as it appeared there was Report Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20211223153856
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: SALLY'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565800494
VISIT DATE: 05/16/2023
NARRATIVE
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additional medical information not reviewed during the original investigation and as a result, this complaint (control # 29-AS-20211223153856) was written.

On 12/24/2021, LPA Kelly Dulek conducted the initial complaint inspection. The LPA conducted an interview with the Administrator from 11:32 a.m. until 12:15 p.m. At 12:15 p.m., the LPA conducted a physical plant tour with the Administrator. The LPA confirmed that CCLD had already obtained all pertinent records in the facility’s possession for R1 and therefore no additional copies were obtained during the visit.

On 03/11/2022 at 3:41 p.m., LPA Camara returned to the facility to determine if there were additional documents to obtain. The LPA spoke with the Administrator over the phone and conducted an interview with the Assistant Administrator. At 3:45 p.m., the LPA obtained pertinent documents.

On 09/02/2022, LPA Camara and LPA Dulek conducted a subsequent complaint visit. The LPAs toured the facility at 10:15 a.m., interviewed the Administrator at 10:20 a.m., interviewed Staff #2 (S2) at 1:18 p.m. and interviewed Staff #3 (S3) at 1:36 p.m. The LPAs also reviewed and obtained the facility’s bowel movement (BM) charting which was not filed with R1’s facility file. S2 worked at the facility the first few months of R1’s stay. S3 did not work at the facility during R1’s stay. Both staff explained how they were instructed to complete the BM charting, though it was not specifically reflective of R1’s (or any resident’s) actual bowel movement. For example, if R1 had three small bowel movements one day, staff would just log it as one large bowel movement. According to the BM charting, R1 did not have an interruption of having BMs.

On 4/1/2022 and 11/18/2022, the Department’s Program Clinical Consultants (PCC) reviewed the case, including all medical records obtained from medical facilities and records obtained from the facility.

It was determined that the facility staff failed to follow R1’s 06/10/2020 hospital’s discharge instruction that indicated to “avoid constipation” and to seek immediate medical care if unable to pass gas and / or stools. Since R1 was assessed to have limited ability in verbalizing his needs, R1 was to be monitored for any signs of constipation and the physician was to be notified of any change in condition. R1 required hands-on facility staff assistance with bathing, incontinence care and transferring from bed to wheelchair. R1 had been sent to the ED by the facility due to altered level of consciousness, and low blood pressure. The facility staff failed Report Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20211223153856
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: SALLY'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565800494
VISIT DATE: 05/16/2023
NARRATIVE
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to notice R1 was experiencing constipation for a period of time as evidenced by the “marked gas and fluid distention of the colon” as noted in the hospital records. It was the opinion of several appropriately skilled professionals, that this led to fecal impaction, bowel obstruction and septic shock, which later resulted in R1’s death. Although staff interviews and the BM chart stated and documented that R1 had daily bowel movements prior to R1’s hospitalization, the computerized tomography (CT) scan of R1’s bowels reviewed by the appropriately skilled professionals provided factual evidence for them to opine that the information was not accurate given the degree of bowel impaction/obstruction.

Therefore, it was determined that based on these findings, the allegation stating that R1’s death was due to inadequate care and supervision is found to be SUBSTANTIATED at this time.

Regarding the allegations “Due to facility neglect, R1 developed septic shock,” “Due to facility neglect, R1 developed a bowel obstruction,” and “Due to facility neglect, R1 developed a fecal impaction of unknown etiology:”

A clinical review conducted by the PCC reflected the following:

R1’s physician’s report dated 01/31/2020, just prior to R1’s admission to the facility, indicated a diagnosis of Alzheimer’s Dementia. At that time, R1’s ability to communicate needs was marked as very limited and R1 was unable to administer or store their own prescription and PRN (‘pro re nata,’ or ‘as needed’) medications. A review of R1’s Centrally Stored Medication Record, indicated a prescription (Rx#191408) of Senna 8.6 Tab to be taken every day on as needed basis was filled on December 12, 2020, and again on January 11, 2021 as prescribed by the physician. There was no evidence the resident was assisted with self-administration of this medication, nor evidence the physician was contacted to report symptoms of constipation after August 3, 2020. The last documented date the facility assisted the resident to self administer this medication as prescribed was August 3, 2020.

Emergency Department (ED) documentation reviewed indicated that R1 was admitted to the hospital on 02/01/2021, at 10:10 a.m. and had been sent to the ED by the facility due to altered level of consciousness, and low blood pressure. The facility failed to notice R1 had been constipated for a period of time as evidenced by the “extensive,” “large,” “marked” fecal impaction that resulted to “marked gas and fluid distention of the colon.” Fecal impaction is caused by chronic (persistent or long-lasting) constipation. A Report Continued on LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20211223153856
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: SALLY'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565800494
VISIT DATE: 05/16/2023
NARRATIVE
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surgery consult dated 02/01/2021, indicated the fecal impaction was “extensive.” Additionally, critical level of lactic acidosis (when there is too much acid in the body, not enough oxygen in the cells leading to impaired organ functioning) was noted from the laboratory results at 10:39 a.m. Severe sepsis (when one or more organs of the body become damaged due to the inflammatory response of the body to fight off infection) was noted at 1:30 p.m. Consultation note on the same day indicated that “patient’s clinical picture is consistent with septic shock and multiorgan failure.”

Although staff interviews and the facility Bowel Movement (BM) chart stated and documented that R1 had daily bowel movements prior to R1’s hospitalization, the computerized tomography (CT) scan of R1’s bowels reviewed by the appropriately skilled professionals provided factual evidence for them to opine that the information was not accurate given the degree of bowel impaction/obstruction. R1 passed away on 02/02/2021 at 7:00 a.m. R1’s Death Certificate listed the sequential causation of the immediate cause of death as follows: fecal impaction caused bowel obstruction that led to septic shock, which was the immediate cause of R1’s death.

A $500 immediate civil penalty is assessed today. The Facility Designee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f).

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

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

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20211223153856
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: SALLY'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565800494
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2023
Section Cited
HSC
1569.312(e)
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§1569.312 Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents...to ensure their general health, safety, and well-being.
This requirement is not met as evidenced by:
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Licensee will submit a plan to ensure proper care and supervision is being provided to the residents. Submit to CCL by POC due date.

An immediate civil penalty of $500 is warranted in with California Health and Safety Code Section 1548(c)(1).
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Based on interviews and records review, the licensee did not comply with the section cited above as R1’s physician’s orders were not followed which resulted in R1 experiencing fecal impaction, bowel obstruction and sepsis, which led to R1’s death and posed an immediate health risk to residents in care.
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Type A
05/23/2023
Section Cited
CCR
87466
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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided when such observation reveals unmet needs...responsible person, if any.
This requirement is not met as evidenced by:
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Licensee will submit a plan on how to ensure staff monitor residents for any change in condition or submit a plan of staff training with an appropriately skilled professional by POC due date.

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Based on interviews and record review, the licensee did not comply with the section cited above by not ensuring R1’s discharge directions were followed and not monitoring R1 for any change in condition, which posed an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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
12/23/2021 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20211223153856

FACILITY NAME:SALLY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
565800494
ADMINISTRATOR:KAYHAN MOJABIFACILITY TYPE:
740
ADDRESS:928 CARISSA COURTTELEPHONE:
(805) 384-8043
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 6DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Sara JacksonTIME COMPLETED:
11:18 AM
ALLEGATION(S):
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Resident was not allowed visitors
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kelly Dulek and Teresa Camara conducted an unannounced subsequent complaint investigation with the purpose of delivering findings for the allegation listed above. LPAs met with Facility Designee Sara Jackson and discussed the reason for today’s visit. Entrance interview conducted.

Previously, LPA Dulek conducted an initial complaint inspection on 12/24/2021. The LPA conducted an interview with the Administrator when the inspection began. At 12:15 PM the LPA, along with the Administrator, conducted a brief physical plant tour and interviewed the Administrator throughout the visit. On 09/02/2022, LPA Dulek conducted a subsequent complaint inspection, during which LPA, along with Administrator conducted a physical plant tour beginning at 10:15 AM. LPA interviewed the Administrator throughout the visit, interviewed staff at 01:18 PM and 01:37 PM. LPA reviewed pertinent documents and obtained copies of records. Additionally, CCLD’s Investigations Branch (IB) investigator Douglas Real
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20211223153856
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: SALLY'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565800494
VISIT DATE: 05/16/2023
NARRATIVE
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conducted staff interviews and obtained and reviewed relevant documentation during a related investigation. Throughout the course of the investigation, all information obtained was reviewed, and the following was then determined:

The complaint alleges that Resident #1 (R1) was not allowed visitors, referring to the resident’s conservator not allowing family to visit R1. Record review revealed that R1 moved into the facility on 02/05/2020. Interview revealed that R1’s family member did visit around the time R1 moved into the facility. On 03/17/2020, Stay Well at Home orders were issued by the Governor, which urged all Californians to shelter in place due to the COVID-19 pandemic. These orders were extended on 03/31/2020 and again on 04/18/2020. Additionally, on 06/01/2020, Ventura County Public Health Officer Dr. Levin issued guidance specific to Long-Term Care Facilities. This guidance allowed for 6-foot socially distanced outdoor visits, “door visits” or drive by car visits only, with both resident and visitor wearing masks. Additionally, this guidance allowed for indoor visitation for bedridden or hospice residents, but neither of these scenarios were applicable to R1. At that time, although outdoor visits were permitted, alternative types of visits were strongly encouraged, such as virtual visits via Skype or Zoom. This guidance remained in place throughout the duration of R1’s time residing at the facility. R1 was hospitalized as of 02/01/2021 and passed away at the hospital on 02/02/2021. All guidance from Ventura County Public Health related to COVID-19 restrictions was rescinded on 03/19/2021, which allowed the option for indoor visits in accordance with CCLD’s guidance as of the date of issuance. Additional interviews revealed that R1’s family member called the facility throughout the time R1 resided at the facility and staff did speak with the family member when they called. Staff interviews revealed that R1’s family member did not attempt to visit R1, nor did they request to schedule an outdoor visit. Administrator interview revealed that the facility followed all Public Health guidance during the COVID-19 pandemic. At the time of the complaint allegation, all visitation was limited due to the Public Health Orders in place, not due to the facility staff. Based on interviews and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that “resident was not allowed visitors” is deemed UNSUBSTANTIATED at this time.

No citations issued related to this allegation. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8