565800682-5-1-2024-29-AS-KHEN-D5KUCL-20240524152806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800682
Report Date: 05/01/2024
Date Signed: 05/01/2024 03:21:42 PM

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
01/09/2023 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230109102247

FACILITY NAME:	ALMAVIA OF CAMARILLO		FACILITY NUMBER:	565800682
ADMINISTRATOR:	MATTHEW HATHWAY		FACILITY TYPE:	740
ADDRESS:	2500 NORTH PONDEROSA DRIVE		TELEPHONE:	(805) 388-5277
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	100	CENSUS: 55	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Mike O'Neill, Executive Director		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff did not provide assistance to resident in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted subsequent complaint investigation with the purpose of delivering findings for the allegation listed above. LPA arrived at the facility at 12:50PM and met with Executive Director (ED) Mike O’Neill. Entrance interview conducted.

During the initial complaint visit, conducted on 01/17/2023, LPA interviewed ED Matthew Hathway at 02:55PM, toured the facility with ED Hathway at 03:32PM, conducted resident interview at 03:40PM, and LPA gathered copies of pertinent documents. No immediate health and safety hazards were identified during facility tour. Throughout the course of the investigation, LPA spoke both in person and telephonically with facility staff related to the complaint allegation, as well as other relevant parties. The following was then determined:

Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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-20230109102247

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: ALMAVIA OF CAMARILLO	FACILITY NUMBER: 565800682
	VISIT DATE: 05/01/2024

NARRATIVE

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It was alleged that Resident #1 (R1) was escorted to their room after dinner and left in their wheelchair for a lengthy period of time, even when R1 verbally requested transfer assistance. Record review revealed that R1 does require transfer assistance and escorts. Needs and service appraisal and interview indicate that staff utilize a Hoyer lift, as well as a 2-person assist for all of R1’s transfers. In-service training records reflect that facility staff did receive training in using R1’s Hoyer lift, as well as training for R1’s service plan, which included additional status checks and transfer assistance. Interview with staff revealed that due to a personality complaint/conflict, Staff #1 (S1) was removed from R1’s direct care prior to receipt of the complaint. At the time of the alleged incident, there were 3 staff working – 1 (one) medication technician and 2 (two) care staff, including S1. As R1 is a 2-person assist, the other 2 (two) staff present were needed to assist R1 with their transfer out of their wheelchair following dinner. Interview revealed that the medication technician escorted R1 back to their room around 06:30PM, but there was no second staff available to assist with R1’s transfer at that time. R1 and staff indicated that no one returned to R1’s room until around 08:00PM, when the medication technician arrived to assist R1 with their scheduled medication. At that time again, only 1 (one) staff was present, so R1 was unable to be transferred. At approximately 08:30PM, R1’s family member arrived at the facility to discover that R1 had been transferred to their bed, instead of their recliner chair as requested. Interview with then-ED revealed that “we did blow it…per [R1]’s routine, [R1] should have been transferred back when [R1] was brought back to her room after dinner. The staff didn’t follow up after that to get her transferred.” Based on interview and record review, there is sufficient evidence to support the allegation, therefore the allegation that “staff did not provide assistance to resident in a timely manner” is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230109102247

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: ALMAVIA OF CAMARILLO	FACILITY NUMBER: 565800682
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/15/2024 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living...as specified in Section 87608, Postural Supports. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	During today's visit, LPA confirmed that training has been completed in basic services for care staff since the allegation. POC cleared.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the above cited section, as R1 was not provided timely transfer assistance, which posed a potential health and personal rights risk to residents in care.	8 9 10 11 12 13 14
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	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.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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