565800734-4-1-2021-29-AS-ASMH-BZNUX4-20210401155743

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800734
Report Date: 04/01/2021
Date Signed: 04/01/2021 03:58:21 PM

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:	HILLCREST ROYALE		FACILITY NUMBER:	565800734
ADMINISTRATOR:	INGA JAKOBOVICH		FACILITY TYPE:	740
ADDRESS:	190 EAST HILLCREST DRIVE		TELEPHONE:	(805) 371-0035
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	145	CENSUS: 87	DATE:	04/01/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Inga Jakobovich		TIME COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith initiated a Case Management-Incident visit to the facility above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually via FaceTime with Administrator Inga Jakobovich.

On 04/01/2021, the facility submitted an Unusual Incident Report, noting that on 3/16/2021, redness was observed near Resident #1's (R1) coccyx. R1 was taken to urgent care and home health was initiated. Per the report, the wound was staged as a Stage 2, possibly a Stage 3 pressure injury. A wound specialist came to assess and daily nursing visits began 3/18/2021. The wound was reassessed on 3/30/2021 and it was confirmed that although the wound was not infected, it was identified as a Stage 4 pressure injury. R1 was transported to the hospital on 3/30/2021 and remains at the hospital at this time. The Administrator stated that they left a message for the On-Duty Worker regarding this incident on approximately 3/19/2021.

During today’s visit, the LPA completed a virtual physical plant tour with the Administrator. No immediate health and safety concerns were observed during today’s virtual tour.

Further investigation is required prior to issuing findings. Exit interview conducted. A copy of the report was emailed for signature. The LPA requested pertinent documents to be emailed or faxed to the Department within the next 24-48 hours.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

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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