565801215-12-12-2024-29-AS-BBAI-DBVTEB-20241212133939

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801215
Report Date: 12/12/2024
Date Signed: 12/12/2024 01:39:52 PM

Document Has Been Signed on 12/12/2024 01:39 PM - 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:	ANGELS II		FACILITY NUMBER:	565801215
ADMINISTRATOR/ DIRECTOR:	JOANN TRUPIANO		FACILITY TYPE:	740
ADDRESS:	2375 MCDONALD COURT		TELEPHONE:	(805) 404-5201
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 6	DATE:	12/12/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:50 PM
MET WITH:	Honorata Perla Avestro		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

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 12/12/2024, Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management visit to issue a civil penalty per Health and Safety Code §1569.49(e). Upon arrival LPA met with staff Honorata Perla Avestro and explained the reason for the visit. Administrator Joann Trupiano was contacted and stated they were unable to be on site for the visit, but stated Honorata Perla Avestro could sign in their place. On May 4, 2023, the Department received a complaint alleging failure to seek timely medical attention and questionable death. Resident #1 (R1) sustained an unwitnessed fall at the facility and staff delayed contacting emergency services. R1 was transported to the hospital and died the next day. The Department initiated the complaint investigation on May 5, 2023. On April 18, 2024, the allegations were substantiated, and the licensee was cited for violating California Health and Safety Code Section 1569.312(a) Basic Services Requirements as it was determined facility staff did not properly supervise R1. The improper supervision of R1 resulted in R1 falling and sustaining a traumatic subdural hematoma, resulting in death. The licensee was also cited under California Code of Regulations (CCR) Title 22, Section 87465(g) Incidental Medical and Dental Care, as it was determined facility staff did not seek timely medical attention when R1 fell and sustained facial and head injuries; yet was put to bed. The investigation revealed that R1 was admitted to Angels II on April 19, 2022, after discharge from a skilled nursing facility. The discharge summary indicated that R1 needs assistance with activities of daily living, supervision/assistance during meals, ambulation, and transfer. Since admission, R1 suffered a total of four unwitnessed falls. On January 17, 2023, R1 was brought to a local hospital by the Sheriff’s with a chief complaint of hip pain. Facility staff left R1 at the facility’s backyard unsupervised and R1 wandered off into the community. On April 12, 2023, R1 suffered a second unwitnessed fall, staff noticed a bump on their forehead and bruising started to appear around their left eye.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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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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: ANGELS II	FACILITY NUMBER: 565801215
	VISIT DATE: 12/12/2024

NARRATIVE

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Continued from 809

R1 was asked to start using their walker. Licensee had identified that R1 “has severe dementia and memory issues, trying to encourage R1 to use a walker is difficult. Caregivers are using standby assistance when R1 is ambulating around the house. R1 is very dependent and has to be observed at all times”. On April 22, 2023, R1 informed responsible person that they fell overnight, this incident was not reported to the Department or the responsible person.

At around 9 a.m. on April 25, 2023, information obtained revealed that R1 suffered another unwitnessed fall. Facility staff informed home health agency and was advised to contact 9-1-1 immediately at around 9:30 a.m. The unusual incident sent to the Department identified the fall to occur at around 10:30 a.m. The Electronic Patient Care Report confirmed "dispatch notified" occurred at 10:52 a.m. on April 25, 2023, when R1 was sent to a local hospital. It was notated on hospital records that the reason of the visit was an unspecified intracranial injury. R1 was found unresponsive at the facility. Staff did not follow directions of home health to contact 9-1-1 immediately until R1’s responsible person arrived and observed that R1 was unconscious. The licensee/administrator and staff admitted that calling 9-1-1 was applicable only after a non-medically trained staff conducted an evaluation of a resident’s visible or non-visible injuries. Facility staff also informed the responsible person that 9-1-1 was not called as the cost is not covered by “social security”. The medical staff at the hospital documented that R1 "did not regain consciousness" while at the emergency department. R1 was discharged to "Hospice" on April 26, 2023, early in the day before passing away on that same day. Per the Ventura County Medical Examiner Autopsy Report, the cause of death was listed as subdural hematoma due to blunt force head trauma.

At the time of the case management visit on April 18, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in the death of R1 due to lack of care and supervision. This is evidenced by the licensee’s failure to address R1’s increased care needs which resulted in the multiple falls of R1, which ultimately led to the death of R1.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ANGELS II	FACILITY NUMBER: 565801215
	VISIT DATE: 12/12/2024

NARRATIVE

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Continued from 809-C

Today, 12/12/2024, the Department is issuing a civil penalty per Health and Safety Code §1569.49(e) in the amount of $15,000 for a violation that the Department determined resulted in the death of R1. However, since an immediate civil penalty of $500 was previously issued on April 18, 2024, the amount of the civil penalty issued is reduced to $14,500. A copy of the LIC 421D was given to the Honorata Perla Avestro and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Honorata Perla Avestro signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

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