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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800845
Report Date: 01/21/2022
Date Signed: 01/21/2022 06:40:30 PM



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
06/18/2021 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20210618141714
FACILITY NAME:ANGELS ON TRACYFACILITY NUMBER:
565800845
ADMINISTRATOR:JO ANN TRUPIANOFACILITY TYPE:
740
ADDRESS:2409 TRACY AVE.TELEPHONE:
(805) 583-3293
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:0CENSUS: 0DATE:
01/21/2022
UNANNOUNCEDTIME BEGAN:
05:45 PM
MET WITH:Jo Ann TrupianoTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff failed to seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Zabel Chochian conducted a subsequent telephonic complaint visit to deliver the finding for the above allegation, as the facility was closed effective 08/26/2021. LPA Chochian spoke with Administrator, Joann Trupiano and the reason for the call was explained.

Following is a summary of the investigation:

Information was received that Resident #1 (R1) sustained a fall on 06/13/2021 and did not receive any medical attention until the following day. Initial visit was conducted by LPA Chochian on 06/21/2020, at approximately 10:50 a.m. LPA Chochian met with staff and, a physical plant tour was conducted at approximately 11:15 a.m. LPA also spoke with Licensee/Administrator Joann Trupiano during the initial visit and explained that this case will be referred to the Community Care Licensing Division’s (CCLD) Investigation Branch (IB) for investigation. (continue to LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20210618141714
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: ANGELS ON TRACY
FACILITY NUMBER: 565800845
VISIT DATE: 01/21/2022
NARRATIVE
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The case was referred to the CCLD’s IB on 06/18/2021, and was assigned to Special Investigator, Peter Zertuche, on 06/21/2021. The investigation consisted of an interview with resident #1’s (R1) responsible person (RP) on 06/24/2021, at approximately 10:30a.m., an interview with reporting party on 06/24/2021 at approximately 1:45pm; interview with facility resident on 07/07/21, at approximately 2p.m.; interview with facility staff on 07/13/2021, at approximately 1:30 p.m. and an interview with the facility administrator on 08/04/2021, at approximately 2 p.m. The investigator also obtained and reviewed resident #1’s facility and hospital medical records. R1 was non-verbal therefore not able to be interviewed.

The interviews revealed that on the night of 06/13/2021, R1 fell to the ground while being assisted up from the sofa by staff. R1 was assisted back up by staff and taken to bed. R1 was taken to the hospital the following day by R1’s responsible person since R1 was observed to be in pain and unable to stand with-out assistance. Staff interviewed confirmed that R1 was unable to stand with-out assistance post fall.

Medical Records reviewed indicate resident #1 was admitted to the hospital on 06/14/2021 due to a fall at the facility on 06/13/2021. Resident #1 was diagnosed with a fractured hip requiring hip replacement surgery. Based on interviews conducted and records reviewed, the department does have sufficient information to support the allegation “Staff failed to seek medical attention for resident in a timely manner”. Allegation is deemed Substantiated at this time.


Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiency cited (Refer to LIC LIC9099-D). Exit interview conducted. Copy of report and appeal rights provided via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20210618141714
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: ANGELS ON TRACY
FACILITY NUMBER: 565800845
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2022
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health....


This requirement is not met as evidenced by:
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Facility closed effective August 26, 2021.
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Based on interview and record review, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, which poses an immediate health and safety risk to residents 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: Desaree PereraTELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/18/2021 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20210618141714

FACILITY NAME:ANGELS ON TRACYFACILITY NUMBER:
565800845
ADMINISTRATOR:JO ANN TRUPIANOFACILITY TYPE:
740
ADDRESS:2409 TRACY AVE.TELEPHONE:
(805) 583-3293
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:0CENSUS: 0DATE:
01/21/2022
UNANNOUNCEDTIME BEGAN:
05:45 PM
MET WITH:Jo Ann TrupianoTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Resident sustained fracture due to staff negligence
Resident sustained multiple pressure injuries while in care
Staff failed to meet the resident's hygiene needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Zabel Chochian conducted a subsequent telephonic complaint visit to deliver the finding for the above allegation, as the facility was closed effective 08/26/2021. LPA Chochian spoke with Administrator, Joann Trupiano and the reason for the call was explained.

Following is a summary of the investigation:
Allegation: Resident sustained a fracture due to staff negligence.
This case was referred to the Community Care Licensing Division’s Investigation Branch on 06/18/2021 and was assigned to Special Investigator, Peter Zertuche, on 06/21/2021. The investigation consisted of an interview with Resident #1’s (R1) responsible person (RP) on 06/24/2021, at approximately 10:30a.m.; interview with reporting party on 06/24/2021, at approximately 1:45pm; interview with facility resident on 07/07/21, at approximately 2p.m.; interview with facility staff on 07/13/2021, at approximately 1:30 p.m. and an interview with the facility administrator on 08/04/2021, at approximately 2 p.m. R1 was non-verbal therefore not able to be interviewed. Investigator also obtained and reviewed R1’s records. (continue to LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20210618141714
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: ANGELS ON TRACY
FACILITY NUMBER: 565800845
VISIT DATE: 01/21/2022
NARRATIVE
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Interviews conducted, and records reviewed revealed that the 06/13/2021, fall was witnessed by staff. Staff were assisting resident up from the sofa and resident lost balance and fell. R1’s responsible person expressed that the fall incident was an accident and not due to staff negligence. There were no other witnesses alleging neglect resulting in the fall/fracture.

Allegation: Resident sustained multiple pressure injuries while in care and staff failed to meet the resident’s hygiene needs.

It was reported that R1 has several pressure injuries on shoulder, left elbow, left arm and one on the back. In addition, it was reported that R1 was not given a shower, had dirty clothes and socks on for a week.
Interview attempted with reporting party on 06/24/2021, however no additional details or supporting information was provided. Interview with facility staff, and R1s responsible person revealed that R1 was receiving wound care service from Infinite Home Health. Staff interviewed reported that R1 was incontinent therefore checked on and repositioned at least every two (2) hours. Staff and R1’s responsible person confirmed that R1 is showered at least twice a week, if resident allowed. During initial visit to the facility on 06/21/2021, residents of the facility observed in clean and dry clothing.

Records obtained from Infinite Home Health indicated initial nursing valuation/ assessment was conducted on 06/09/2021. During this initial visit, R1 was diagnosed with two pressure injuries, one on the left buttocks and one on the right buttocks, both listed as stage II. The left buttocks pressure injury was sized at 1x1x0.1 cm and the right one was sized at 1.5x1.5x0.1cm. There were no additional visit notes. It was verified with Infinite Home Care that there were no additional records as R1 went to the hospital on 06/14/2021.

Medical records obtained from Kaiser Permanente indicated, R1 was diagnosed with two pressure injuries, one on the left buttocks and one on the right buttocks. On 06/15/2021, notes indicated R1 had a wound to the left buttocks, but the earliest staging with sizing were documented on 06/16/2021, which show unstageable wounds (left side was sized at 3cm x 1.5cm and the right one was 2cm x 1.5cm). There were no photos of these wounds and the depth size was not noted.

Based on the information obtained, there is insufficient evidence to support allegations. Therefore, allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5