565800494-9-8-2023-29-AS-ZCHN-CVGN32-20230908100536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800494
Report Date: 09/08/2023
Date Signed: 09/08/2023 10:06:42 AM

Document Has Been Signed on 09/08/2023 10:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	KAYHAN MOJABI		FACILITY TYPE:	740
ADDRESS:	928 CARISSA COURT		TELEPHONE:	(805) 384-8043
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY: 6		CENSUS: 5	DATE:	09/08/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Sara Jackson		TIME COMPLETED:	10:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On September 8, 2023, Licensing Program Analyst (LPA) Zabel Chochian met with Sara Jackson for an unannounced Case Management visit to issue a civil penalty per Health and Safety Code §1569.49(e). On April 20, 2021, the Department received a complaint alleging a resident (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. The subsequent complaint received December 23, 2021, with the same allegation, further alleged that due to facility neglect, a resident (R1) developed septic shock, bowel obstruction and fecal impaction of unknown etiology. The Department initiated the complaint investigation on April 21, 2021. The investigation revealed that facility staff failed to follow R1’s hospital discharge instructions dated June 10, 2020, 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 own 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. A review of R1’s centrally stored medication record, indicated a prescription of Senna 8.6 Tab to be taken every day and on an as needed basis was filled on December 12, 2020, and again on January 11, 2021, as prescribed by the physician. There was no evidence R1 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 R1 to self-administer this medication as prescribed was August 3, 2020.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/08/2023

NARRATIVE

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On February 1, 2021, R1 was sent to the emergency department by the facility due to an altered level of consciousness and low blood pressure. The facility staff failed 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 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 February 2, 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.

On May 16, 2023, the allegations were substantiated, and the licensee was cited for violating California Health and Safety Code Section 1569.312(e) Basic Services Requirements due to the licensee’s failure to follow R1’s physician’s order which resulted in R1 experiencing fecal impaction, bowel obstruction and sepsis, which led to R1’s death. The licensee was also cited under California Code of Regulations (CCR) Title 22, Section 87466 Observation of the Resident due to the licensee’s failure to ensure R1’s discharge directions were followed and failure to monitor R1 for any change in condition. An immediate civil penalty of $500 was also assessed for a violation of California Health and Safety Code Section 1569.49(c)(1). The licensee was also informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in the death of R1. This is evidenced by the licensee’s failure to follow R1’s physician’s order and failure to monitor R1 for a change in condition, which resulted in R1 experiencing fecal impaction, bowel obstruction and sepsis, which led to R1’s death.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/08/2023

NARRATIVE

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Today, September 8, 2023, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(e) in the amount of $15,000 for a violation that the Department determined resulted in the death of R1. However, since an immediate civil penalty of $500 was previously issued on May 16, 2023, the amount of the civil penalty issued is reduced to $14,500.

A copy of the LIC 421D was given to the Sara Jackson and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Sara Jackson's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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