<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801076
Report Date: 01/21/2022
Date Signed: 01/21/2022 05:45:23 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
10/22/2019 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 31-AS-20191022104510
FACILITY NAME:GOLDEN ACRES RCFEFACILITY NUMBER:
565801076
ADMINISTRATOR:BABY JANE ANGELESFACILITY TYPE:
740
ADDRESS:6437 KEYSTONE STREETTELEPHONE:
(805) 577-6936
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:4CENSUS: 0DATE:
01/21/2022
UNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Baby Jane AngelesTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed pressure injury while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amended report from the report issued on 10/27/2020.

Licensing Program Analyst (LPA) Zabel Chochian initiated a subsequent complaint visit to deliver the finding for the above allegation. Following is a summary of the investigation:
Allegation - Resident developed pressure injury while in care - It was reported that resident #1 was found with a pressure injury on 10/12/19 - immobilizer on R1’s leg caused a pressure injury on the back part of the right leg (near ankle) which seems to be devise related.

On 10/31/2019, LPA Mita Amin completed the initial visit and discussed allegations with administrator and requested pertinent documents. Staff were also interviewed on this day between 4pm-4:30pm. On 2/13/2020, LPA Zabel Chochian conducted a subsequent visit and conducted interview with administrator, staff and resident #1 (R1) between 1:30pm - 3pm. On this day LPA also toured the facility and observed residents in care. On 2/24/2020, the LPA interviewed R1's family member at approximately 11am. (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 31-AS-20191022104510
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: GOLDEN ACRES RCFE
FACILITY NUMBER: 565801076
VISIT DATE: 01/21/2022
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
Medical records were also obtained and reviewed. Facility staff interviewed on 02/13/2020 expressed that R1 was provided with proper care and attention. Staff expressed that the injury to R1’s right ankle was caused by the immobilizer device. R1’s responsible person interviewed on 02/24/2020 expressed that R1 was provided with proper care and attention. Medical records reviewed revealed that R1 was discharged from the hospital on 9/14/2019 with orders for Home Health services. Home health service was not initiated until 10/11/2019. R1’s records reviewed revealed that there was a delay in home health services which administrator did not follow up on consistently/timely.

This case was further reviewed by the Department’s Program Clinical Consultant. It was determined that the delay in obtaining home health services; facility staff not following doctors/home health nurse instructions on the use of the immobilizer and facility staff not properly observing R1’s right leg, resulted in development of stage 3 pressure injury to R1’s right ankle.

Based on the information above allegation “Resident developed pressure injury while in care” is deemed Substantiated at this time.

Pursuant to Title 22 CA Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).
Exit interview conducted. Copy of report and appeal rights provide to Administrator by 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
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
10/22/2019 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 31-AS-20191022104510

FACILITY NAME:GOLDEN ACRES RCFEFACILITY NUMBER:
565801076
ADMINISTRATOR:BABY JANE ANGELESFACILITY TYPE:
740
ADDRESS:6437 KEYSTONE STREETTELEPHONE:
(805) 577-6936
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:4CENSUS: 0DATE:
01/21/2022
UNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Baby Jane AngelesTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Staff is not following licensed physician orders.
-Staff failed to administer resident's medication as prescribed.
-Staff failed to meet the resident's hygiene needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amended report from the report issued on 10/27/2020.

Licensing Program Analyst (LPA) Zabel Chochian initiated a subsequent complaint visit to deliver the findings for the above allegations.

Following is a summary of the investigation:

On 10/31/2019, LPA Mita Amin completed the initial visit and discussed allegations with administrator and requested pertinent documents. Staff were also interviewed on this day between 4pm-4:30pm. On 2/13/2020, LPA Zabel Chochian conducted a subsequent visit and conducted interview with administrator, staff and resident #1 (R1) between 1:30pm - 3pm. On this day LPA also toured the facility and observed residents in care. On 02/24/2020, LPA Chochian interviewed R1’s responsible person. Medical records were also obtained and reviewed. (continue to LIC 9099C)
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: 3 of 5
Control Number 31-AS-20191022104510
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: GOLDEN ACRES RCFE
FACILITY NUMBER: 565801076
VISIT DATE: 01/21/2022
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
Allegation 1) - Staff is not following licensed physician orders - Information was received that staff did not allow the resident #1's legs to dangled 3 times per day and the resident is not being moved. According to staff and administrator R1 was discharged from hospital on 9/14/2019. Home Health services did not start until 10/11/2019. Administrator and staff reported that R1 was repositioned and moved every 2 hours.

Allegation 2) - Staff failed to administer resident's medication as prescribed - Information was received that R1's pain medication was not refilled - Administrator and family both reported that there was 0 refills therefore this medication could not be refilled until primary physician evaluated R1. No order was written until 10/21/2019.

Allegation 3) - Staff failed to meet the resident's hygiene needs - Information provide was that due to resident poor skin condition was due to staff not meeting resident's hygiene needs. Administrator and staff interviewed revealed R1 was bathed (in bed) every day since discharged from hospital. Family member interviewed reported no issues or concerns with the care of R1.

Based on the information obtained, there is insufficient evidence to support allegations above. Therefore, allegations above are deemed unsubstantiated at this time.

Exit interview conducted. Copy of the report provided to Administrator by 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: 4 of 5
Control Number 31-AS-20191022104510
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: GOLDEN ACRES RCFE
FACILITY NUMBER: 565801076
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2022
Section Cited
CCR
87466
1
2
3
4
5
6
7
Observation of the Resident:The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs....
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee/Administrator agreed to review section cited; provide in-services training to staff and submit written self-certification of understanding requirements of this secition. Also submit copy of in-service provided to staff.
8
9
10
11
12
13
14
Based on interviews and records reviewed it was revealed that staff did not follow doctors/home health nurse instructions on the use of the immobilizer and not properly observing R1’s right leg, resulted in development of stage 3 pressure injury to R1’s right ankle. This poses a 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
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: 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: 5 of 5