565800845-1-23-2022-29-AS-DPEA-CB3VSJ-20220127154136

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800845
Report Date: 01/21/2022
Date Signed: 01/23/2022 11:38:43 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
02/26/2021 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20210226153641

FACILITY NAME:	ANGELS ON TRACY		FACILITY NUMBER:	565800845
ADMINISTRATOR:	JO ANN TRUPIANO		FACILITY TYPE:	740
ADDRESS:	2409 TRACY AVE.		TELEPHONE:	(805) 583-3293
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	0	CENSUS: 0	DATE:	01/21/2022
		UNANNOUNCED	TIME BEGAN:	06:45 PM
MET WITH:	Jo Ann Trupiano		TIME COMPLETED:	07:30 PM

ALLEGATION(S):

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Resident sustained pressure injury while in care
Resident not assisted with incontinence care
Licensee did not assist resident with prescribed medication

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: Regarding Allegations: "Resident sustained pressure injury while in care" and "Resident not assisted with incontinence care" - Reporting party (RP) reported that R1 developed 2-3 pressure injuries near the buttocks area since admission to the facility. RP believes that R1 keeps sustaining pressure injuries at the facility because the resident is not receiving adequate incontinence care. Interview was conducted with reporting party on 03/04/2021, however no additional details or supporting information was provided. Interview conducted with facility staff on 03/05/2021, interview with resident #1 responsible person on 03/04/2021 and records review revealed that R1 did have a history of skin breakdown. According to staff R1 was diabetic which contributed to R1's skin injuries. R1 recieved 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. (cont. to LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (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)

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Control Number 29-AS-20210226153641

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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Staff and resident #1’s responsible person confirmed that R1 was showered at least twice a week if resident allowed. During initial virtual visit to the facility on 03/05/2021, residents of the facility observed in clean and dry clothing. R1 received service for wound care by Infinite Home Health starting on 06/09/2021, which indicates initial nursing evaluation/ assessment. 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. It was verified with Infinite Home Care that there were no wounds greater than stage II prior to 06/09/2021.

Regarding Allegation: Licensee did not assist resident with prescribed medication - RP reported that the responsible person for R1 goes to the facility three times per day to administer R1's medication because facility staff are not assisting R1 with taking medication. Facility staff interviewed denied allegation and reported that all residents receive assistance with the medication as prescribed/allowed. R1's responsible person did not report any issue/concern with R1's medications. Review of R1's centrally stored medication log and the medication administration record did not show any discrepancy.

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 emailed to Licensee.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (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)

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