565800683-10-6-2022-29-AS-KDUK-CJXPPH-20221006112935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800683
Report Date: 10/06/2022
Date Signed: 10/06/2022 11:31:34 AM

Document Has Been Signed on 10/06/2022 11:31 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:	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: 0	DATE:	10/06/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Hannah Robertson & Mark Brassfield		TIME COMPLETED:	11:40 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 10/06/2022, Licensing Program Analyst (LPA) Kelly Dulek met with Business Office Manager Hannah Robertson and Health Services Director Mark Brassfield for a Case Management visit to issue a civil penalty per Health & Safety (H&S) Code §1569.49(f). On May 24, 2021, the Department received a complaint alleging “Facility failed to provide proper care and supervision for Resident #1 (R1) as R1 fell and sustained a fracture.” To investigate, LPAs conducted visits to this facility on May 25, 2021, September 17, 2021, April 8, 2022, and April 12, 2022. The Department conducted an investigation which revealed on March 12, 2021, R1 was hospitalized due to experiencing symptoms of a possible stroke. R1 was discharged back to the facility on March 18, 2021. According to interviews conducted with facility staff and R1’s family, R1 was observed to be extremely weak, more confused, unable to independently walk, and required additional assistance from facility staff. Despite R1’s change of condition, a reappraisal was not conducted after R1’s discharge from the hospital; however, the Associate Care Director (S1), a facility medication technician, and four additional facility caregivers observed and identified R1 to be a fall risk. R1’s family member offered to stay with R1 throughout the night to help provide supervision, but S1 assured R1’s family a sensor mat would be placed next to R1’s bed. In the event R1 got out of bed, the sensor mat would alert staff to respond and assist R1. According to staff interviews, the sensor mat was placed next to R1’s bed by S1. However, S1 was unable to properly program the mat to alert staff and left the malfunctioning mat next to R1’s bed. In addition, the facility staff did not notify R1’s family that the sensor mat was inoperable. Staff indicated they conducted checks on R1 every two hours throughout the night. The following morning, on March 19, 2021 at approximately 5:45 a.m., staff discovered R1 had fallen on the floor in the bathroom during one of their routine checks. R1 was found in a puddle of urine with their pants at knee level and stated to staff that they Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: AEGIS OF VENTURA	FACILITY NUMBER: 565800683
	VISIT DATE: 10/06/2022

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
26
27
28
29
30
31
32

fell. When R1 was asked if R1 was in pain, R1 pointed to their hips and thighs. Facility staff also observed a skin tear on R1’s elbow, requiring gauze and bandaging due to bleeding. Facility staff contacted 9-1-1, and in preparing R1 for transport, staff noticed one of R1’s legs was longer than the other.

Facility and hospital records reflect R1 had diagnoses of dementia, chronic atrial fibrillation, hypothyroidism, hyperlipidemia, hypertension, cerebrovascular accident, chronic obstructive pulmonary disease, anxiety, and a history of seizures. On March 19, 2021 at 12:26 p.m., R1 was admitted to the hospital. R1’s x-rays confirmed a displaced and angulated intertrochanteric fracture of the right femur. On March 20, 2021, R1 underwent open reduction with internal fixation of their right hip. R1 was ultimately placed on hospice and discharged to another licensed residential care facility for the elderly on March 27, 2021.

On April 12, 2022, Licensing staff substantiated the allegation that “Facility failed to provide proper care and supervision for Resident #1 (R1) as R1 fell and sustained a fracture”, and the licensee was cited for violating the California Code of Regulations (CCR) Title 22, 87464(f)(1)(c) Basic Services due to the licensee failing to ensure proper care and supervision for R1 which resulted in R1 sustaining a hip fracture. An immediate civil penalty of $500 was also assessed as a result of this violation. The licensee was also informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49.

Today, 10/06/2022, an additional citation is issued under CCR Title 22, 87463(a)(3) Reappraisals, which states, The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident’s physical, medical, mental and social condition. Significant changes shall include but not be limited to: Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.

The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in R1 sustaining a serious bodily injury while under the care of this facility. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee’s failure to ensure proper care and
Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: AEGIS OF VENTURA	FACILITY NUMBER: 565800683
	VISIT DATE: 10/06/2022

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
26
27
28
29
30
31
32

supervision for R1 resulting in R1 falling, sustaining a hip fracture, which required hospitalization and surgery.

Today, 10/06/2022, the Department is issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on April 12, 2022, the amount of the civil penalty issued is reduced to $9,500.

A copy of the LIC 421D was given to the Health Services Director and Business Office Manager and originals were signed.

Exit interview conducted. A copy of the report was issued. Appeal Rights provided. Health Services Director Mark Brassfield’s signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/06/2022 11:31 AM - It Cannot Be Edited

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: AEGIS OF VENTURA	FACILITY NUMBER: 565800683
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/06/2022 Section Cited	1 2 3 4 5 6 7	87463(a)(3) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's...Prohibited Health Conditions. This requirement is not met as evidenced by
	8 9 10 11 12 13 14	Resident #1 (R1) was readmitted to the facility on 03/18/2021 following a hospitalization, was noted by facility staff to have a change of condition, but no reappraisal was completed, which caused an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14
	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: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4