565800683-4-18-2022-29-AS-KHEN-CDMS5U-20220419133451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800683
Report Date: 04/12/2022
Date Signed: 04/18/2022 10:18:55 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
05/24/2021 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210524120011

FACILITY NAME:	AEGIS OF VENTURA		FACILITY NUMBER:	565800683
ADMINISTRATOR:	BASSEM EL-RABAA		FACILITY TYPE:	740
ADDRESS:	4964 TELEGRAPH ROAD		TELEPHONE:	(805) 650-1114
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	0	CENSUS: 74	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mark Brassfield		TIME COMPLETED:	01:58 PM

ALLEGATION(S):

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Facility failed to provide proper care and supervision for Resident #1 (R1) as R1 fell and sustained a fracture

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit on 04/12/2022 to deliver findings for the above allegation. The initial visit was conducted on 05/25/2021 by LPA JoAnn Rosales and subsequent visits were conducted on 09/17/2021 and 04/08/2022 by LPA Camara. During today’s visit, the LPA met with the facility health services director Mark Brassfield as the administrator, Lance Shenk, was not in. LPA explained the reason for the visit.

On 05/24/2021, the Department received a complaint regarding the allegation the facility failed to provide proper care and supervision for Resident #1 (R1) resulting in R1 falling and sustaining a fracture.

(continued on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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-20210524120011

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: AEGIS OF VENTURA	FACILITY NUMBER: 565800683
	VISIT DATE: 04/12/2022

NARRATIVE

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On 05/25/2021, between 10:50 a.m. and 5:08 p.m., LPA Rosales conducted the initial complaint visit. LPA conducted the following interviews: Staff 1 (S1) at 3:56 p.m., Staff 2 (S2) at 4:20 p.m., Staff 3 (S3) at 4:29 p.m., Staff 4 (S4) at 4:36 p.m., and Staff 5 (S5) at 1:00 p.m. LPA also reviewed and obtained pertinent facility records.

On 09/17/2021, between 9:05 a.m. and 10:03 a.m., LPA Camara conducted a collateral visit to R1’s current residence, and conducted an interview with R1 at approximately 9:15 a.m.

On 09/17/2021, between 11:58 a.m. and 3:10 p.m., LPA Camara conducted a subsequent complaint visit to the facility. LPA Camara conducted the following interviews: Resident 2 (R2) at 2:10 p.m., Resident 3 (R3) at 2:15 p.m., Resident 4 (R4) at 2:20 p.m., Resident 5 (R5) at 2:25 p.m., Resident 6 (R6) at 2:30 p.m., Resident 7 (R7) at 2:35 p.m., Resident 8 (R8) at 2:40 p.m., Resident 9 (R9) at 2:45 p.m., Resident 10 (R10) at 2:50 p.m., Resident 11 (R11) at 2:55 p.m. LPA reviewed facility records, however some of the records requested could not be located. LPA requested to interview Staff 6 (S6), however S6 was on leave from the facility.

On 04/08/2022, between 12:27 p.m. and 1:49 p.m., LPA Camara conducted a subsequent complaint visit to the facility. LPA Camara requested an interview with S6 but learned S6 no longer works at the facility. LPA Camara spoke with the current administrator Lance Shenk, as well as the Health Services Director and Care Director, however none of these individuals worked at this facility during the time this incident occurred. The facility was also able to locate the documents requested during LPA’s last visit to the facility.

LPA Camara attempted to call S6 at the last known phone number the facility had for S6. However the attempts to reach S6 were unsuccessful. Based on CCL records, it does not appear S6 works for any other licensed facilities at this time.

Information gathered throughout the investigation revealed R1 had been hospitalized due to having symptoms of a possible stroke on 03/12/2021. R1 was released back to the facility on 03/18/2021. According to staff and R1’s family, R1 was very weak upon returning to the facility. R1 arrived at the facility around dinner time (recollections of the exact time varies). A reassessment was not completed, however the Associate Care Director (S6) observed R1 to be a fall risk. S6 assured R1’s family there would be a sensor mat placed next to R1’s bed. In the event R1 got out of bed, the sensor mat would alert staff so they could respond. According to staff interviews, the sensor mat was placed next to the bed by S6, however S6 was unable to properly program the mat to alert staff. Staff indicated they conducted checks on R1 every two hours during

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210524120011

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: AEGIS OF VENTURA	FACILITY NUMBER: 565800683
	VISIT DATE: 04/12/2022

NARRATIVE

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the night. The facility staff did not notify R1’s family that the sensor mat did not work. The following morning 03/19/2021 at approximately 5:45 a.m. during one of their checks, staff discovered R1 had fallen on the floor in the bathroom. Staff observed R1 had suffered injuries and called 9-1-1. R1 was admitted to the hospital where R1 was diagnosed with a right hip fracture.

Based on the information obtained during the course of the investigation, it appears the facility failed to ensure proper care and supervision for R1 which resulted in R1 sustaining a hip fracture. Therefore, the allegation is deemed Substantiated at this time.

Pursuant to the California Code of Regulations, Title 22, the following deficiency is cited (please see LIC 9099-D), and an immediate $500 civil penalty was assessed during today’s visit on 04/12/2022. The administrator was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49€ or (f), or 1548(e) or (f).

Exit interview conducted. Today’s report, civil penalty and appeal rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210524120011

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: AEGIS OF VENTURA	FACILITY NUMBER: 565800683
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/25/2022 Section Cited CCR 87464(f)(1)(c)	1 2 3 4 5 6 7	Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the reisident's	1 2 3 4 5 6 7	Licensee will provide training to staff regarding care expectations for residents who are known fall risks and will train staff regarding communication with residents' responsible parties when agreed upon plan of care cannot be met. Evidence of training will be sent to CCL on or before 4/19/2022.
	8 9 10 11 12 13 14	physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by:	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as R1 was not provided a sensor mat to alert staff when R1 got out of bed as promised by S6 and R1 was a known fall risk, which poses an immediate health and safety risk to persons 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.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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