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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801300
Report Date: 12/14/2023
Date Signed: 12/14/2023 05:44:38 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
04/28/2022 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20220428154930
FACILITY NAME:HOME SWEET HOME CAREFACILITY NUMBER:
565801300
ADMINISTRATOR:GLORIA P. VALENCIAFACILITY TYPE:
740
ADDRESS:7520 VAN BUREN STREETTELEPHONE:
(805) 659-4427
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 5DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Gloria Valencia, Administrator; Purbani Fnu, Direct Support Staff and Pho Lany, Direct Support StaffTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care
Staff did not seek medical attention for resident
Staff left resident in soiled diaper for extended period of time
Staff made inappropriate comments towards resident
INVESTIGATION FINDINGS:
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On 12/14/2023, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to facility above to issue final findings. LPA arrived at the facility, met with Direct Support Staff Purbani Fnu and Direct Support Staff Pho Lany in person and administrator Gloria Valencia by telephone as the Administrator was not physically present, and announced the purpose of the visit.

On the allegation: Resident sustained pressure injuries while in care. It is alleged by the Reporting Party (RP) that Resident #1 (R1) had wounds on their sacral area that are about “medium size.” RP stated that they didn’t know what stage the wounds were in.

On 05/02/2022, LPA interviewed Staff members about this allegation who all stated that R1 moved into the facility with a wound on their bottom/tailbone. Staff stated R1 was treated for it and had antibiotics (cream). R1 also received a patch on it and routine cleaning from a Hospice nurse. The facility staff stated they would rotate R1 every 2 hours at minimum. Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
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 4
Control Number 29-AS-20220428154930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME CARE
FACILITY NUMBER: 565801300
VISIT DATE: 12/14/2023
NARRATIVE
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LPA received the Pre-placement Appraisal Information for R1, dated 3/06/2022, that stated R1 had a pressure ulcer on their tailbone. LPA received the Resident Appraisal for R1, dated 04/12/2022, that stated R1 has redness/irritation on the skin of the anal area. Hospice Care Agency documentation from 12/23/2021, 12/29/2021, 1/10/2022, 1/13/2022, 1/17/2022 indicated that R1 had redness/irritation/wounds on their anal/vaginal/tailbone area which were treated weekly by Hospice Agency providers. As R1 moved into the facility on 03/07/2022, the pressure injuries were not sustained while in care at the facility. Based on record review and interview, there was no evidence found to show that the pressure injuries worsened at the facility due to neglect.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff did not seek medical attention for resident. It is alleged by RP that the health of R1 has significantly declined. RP stated that they went to visit R1 and could hear them screaming outside. RP stated that R1 was screaming, presumably in pain, and the facility didn’t call hospice to get any help. RP stated that the facility didn’t give R1 any pain medication and the RP had to have the nurse order some pain medication.

From 05/02/2022-05/04/2022, the LPA assigned to the complaint interviewed Staff members of the facility. Staff members stated that R1 would scream for food and for pain. Staff stated that they would ask R1 to take the PRN pain medication when R1 would scream for pain, but R1 would regularly refuse the PRN medication. Staff stated that R1 was very combative with Staff members and that R1 would yell for food, assistance, water, and pain. Staff members all stated that they would offer R1 their PRN pain medication when R1 yelled at Staff members. The Medication Administration Record (MAR) for R1 from March 2022 and April 2022 indicates that R1 has taken/received the regularly scheduled pain medications on a consistent basis. The PRN pain medication is also marked as having been given to R1 on a consistent basis, except for refusals by R1 to take the medication. The Centrally Stored Medication and Destruction Record for R1 indicates that the facility has continuously ordered medications for R1 when the prior prescription has run out. Medication Administration Record (MAR) for R1 in March 2022 indicates the following: R1 had scheduled medications given 3/13 - 3/31/22, with the PRN pain medication given every 6 hours as needed on 3/16, 3/19, and 3/23/22. Medication Administration Record (MAR) for R1 in April 2022 indicates the following: Regularly scheduled medications were given to R1 from 4/1 - 4/30/22, with the PRN pain medication given every 6 hours as needed on 4/1/22. Continued on 9099-C

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20220428154930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME CARE
FACILITY NUMBER: 565801300
VISIT DATE: 12/14/2023
NARRATIVE
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The Hospice Agency Home Patient Visit log for R1 from 3/12/22-3/21/22 indicated that the Hospice Agency reviewed all medications taken by R1 with the facility on 3/12/22. Additionally, medications were ordered for delivery by the facility on 3/18/22, and that on 3/21/22 R1 declined pain medication after being offered PRN medication for pain by the facility.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff left resident in soiled diaper for extended period of time. It is alleged by the Reporting Party (RP) that on one occasion, Resident #1 (R1) had been sitting in feces and urine most of the day until 5pm, which caused a rash on their buttocks.

On 05/02/2022 the LPA assigned to this complaint obtained a Physician’s Report for R1 dated 03/07/2022 that stated R1 has a Bowel impairment and Bladder impairment which causes R1 to require the wearing of incontinent diapers. According to record review, documentation of scheduled diaper changes for R1 indicates that R1 has diaper changes as needed every 2 hours daily. Date: 3/14/22 Time: 8:00 am, 12:00 noon. Date: 3/15/22 Time: 7:00 am refused, 8:00 am, 12:00 noon, 5:00 pm. Date: 3/18/22 Time: 8:00 am change depend, 12:00 noon, 3:00 pm, 7:00 pm, 10:30 pm. Date: 3/19/22 Time: 8:30 am, 11:00 am, 1:30 am, 5:30 am. Interviews by LPA indicated that Staff members change every resident about every 2-3 hours. When they wake up, after breakfast, after lunch and after dinner, also as needed. Maybe 3 to 5 times a day the Staff members will change a resident, depending on the needs of each resident. LPA did not observe any foul odors in the facility during the complaint investigation visit on 12/14/2023. Residents interviewed by the LPA on 12/14/2023 who require the wearing of incontinent diapers denied any experience of being left in soiled diapers for extended periods of time while in care.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff made inappropriate comments towards resident. It is alleged by the Reporting Party (RP) that Staff members of the facility have been making fun of Resident #1 (R1), including saying that R1 sounds like a dog when R1 is screaming.

Continued on 9099-C

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220428154930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME CARE
FACILITY NUMBER: 565801300
VISIT DATE: 12/14/2023
NARRATIVE
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Through interviews with both Staff members and residents of the facility, LPA found no evidence to corroborate the allegation that Staff members made inappropriate comments toward any resident. Staff members stated to LPA that no Staff member would make fun of any resident, and that Staff members tried to help R1 as best as possible. No resident reported any inappropriate comments being made towards them, and no resident reported overhearing any inappropriate comments being made by Staff members to another resident. Facility Staff notes for the month of March 2022 do not indicate any type of behavior by Staff members that would be considered inappropriate. Provider Communication Forms for R1 from 12/23/21, 12/29/21, 1/10/22, 1/13/22, and 1/17/22 do not have any evidence indicating that Staff members at the facility have made any inappropriate comments to R1 or about R1.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of this Complaint Investigation Report provided to the facility.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4