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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801460
Report Date: 04/22/2022
Date Signed: 04/22/2022 01:41:59 PM

Substantiated


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
01/03/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220103153627
FACILITY NAME:OMNICARE IIFACILITY NUMBER:
565801460
ADMINISTRATOR:KINGA KAZDRONFACILITY TYPE:
740
ADDRESS:154 THAMES STREETTELEPHONE:
(805) 777-8143
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Kinga KozdronTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility staff transferred R1 in a rough manner, resulting in bruising and a fractured sternum
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver the findings for the above
allegation. The LPA met with the Administrator Kinga Kozdron and explained the reason for the visit.

On 1/03/2022, the Department received a complaint of alleging that facility staff handled Resident #1 (R1) in a rough manner, resulting in R1 sustaining extensive bruising and a fractured sternum. Community Care Licensing Division’s Investigations Branch (IB) Investigator Dennis Seng was assigned to the case. The initial visit was conducted on 1/04/2022 from 1:00 p.m. – 2:15 p.m., and the LPA conducted a tour, briefly spoke with staff, and reviewed and obtained copies of pertinent records. IB Investigator Seng interviewed family members of R1 on 1/20/2022 and 3/2/2022; interviewed R1 on 1/20/2022; interviewed four staff members on 1/20/2022; interviewed three residents on 1/20/2022; and, reviewed medical records.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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 6
Control Number 29-AS-20220103153627
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: OMNICARE II
FACILITY NUMBER: 565801460
VISIT DATE: 04/22/2022
NARRATIVE
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Interviews and records review revealed that R1 was admitted to this facility on 12/15/2021 and was discharged from the facility on 12/28/2021. The Physician’s Report, dated 11/08/2021, noted that R1 was deemed bedridden and did not have a history of skin breakdown. Upon admission to this facility, facility staff conducted a body check and noted that R1 did not have any bruises, broken bones, or wounds outside of an identified pressure injury on R1’s sacral region. R1’s pre-assessment appraisal dated 12/20/2021 noted that R1 had been in the bed for over a year at their family’s home and required full assistance. As a result, it was communicated that R1 should slowly transition into getting in and out of the wheelchair or recliner and it was further stated that being placed in the shower would be very difficult for R1.

Investigative interviews revealed that on 12/17/2021, R1 was transferred by Staff #1 (S1) from a wheelchair to R1’s bed. Witnesses to the incident revealed that S1 utilized a one-person transfer by placing their arms under R1’s armpits, hugged R1’s body to their body, and transferred them from the wheelchair to the bed. Witnesses claimed that upon being placed on the bed, R1 screamed and clutched their chest in pain. Further action was not taken at that time.

On 12/22/2021, S1 and Staff #2 (S2) noted that R1 was showered. Staff interviews revealed that R1 was placed in the shower chair, and at times, stood up and held the grab bar in order for staff to wash R1’s bottom. Thereafter, staff claimed that R1 was transferred from the shower chair to the wheelchair up by way of staff placing their arms underneath R1’s armpits. Staff denied claims that R1 expressed any pain during the shower or the subsequent transfers.

However, staff stated that on 12/23/2021, they noticed bruising on R1’s chest, and on R1’s left and right armpits. Thereafter, staff met with R1’s family and communicated the bruising and stated that they could no longer transfer R1 without a hoyer lift. On 12/28/2021, R1 experienced chest pain, and as a result, 9-1-1 was called and R1 was transferred to the hospital. Upon admission to the emergency room, R1 was diagnosed with multiple bruises, a large chest hematoma with internal bleeding, and a fractured sternum. Interviews revealed that staff believed that R1 likely sustained the bruising from the transfers.

Based on the timeline of events, there is sufficient evidence to support the claim that R1 sustained multiple contusions and a fractured sternum while in care. Although it is noted that R1 was on a blood thinner, interviews noted that prior to admission, R1 did not sustain extensive bruising during transfers. In addition, documents submitted prior to R1’s admission to the facility detailed that R1 was bedridden and indicated that staff needed to be careful in handling R1.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220103153627
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: OMNICARE II
FACILITY NUMBER: 565801460
VISIT DATE: 04/22/2022
NARRATIVE
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Whereas the transfers may not have been improper, R1 was handled in a manner in which R1 sustained multiple contusions and a fractured sternum. There was no indication that R1 left the facility at any time from the initial physical examination until the admission to the hospital on 12/28/2021. As such, R1 sustained the injuries at the facility. This allegation is deemed Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Exit interview conducted. A copy of the report was issued, along with appeal rights.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20220103153627
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: OMNICARE II
FACILITY NUMBER: 565801460
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/25/2022
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following...: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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The Administrator agreed to do a following:
1. Submit a Plan of Action/Protocol, detailing how the facility will maintain compliance with ensuring that the needs of residents will be met at all times. Submit protocol to CCL by the POC due date.
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This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 was handled in a manner which resulted in R1 becoming hospitalized with multiple contusions and a fracture, which poses an immediate health and safety risk to residents in care.
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2. Schedule an in-service training that addresses care of bedridden residents. Training needs to be completed in the next two weeks. Submit proof of completion to CCLD.

An immediate civil penalty of $500 will be assessed.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/03/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220103153627

FACILITY NAME:OMNICARE IIFACILITY NUMBER:
565801460
ADMINISTRATOR:KINGA KAZDRONFACILITY TYPE:
740
ADDRESS:154 THAMES STREETTELEPHONE:
(805) 777-8143
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Kinga KozdronTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Due to physical abuse, resident sustained fractured sternum
Facility staff improperly transferred resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver the findings for the above allegations. The LPA met with the Administrator Kinga Kozdron and explained the reason for the visit.

On 1/03/2022, the Department received a complaint of alleging that facility staff handled Resident #1 (R1) in a rough manner, resulting in R1 sustaining extensive bruising and a fractured sternum. Community Care Licensing Division’s Investigations Branch (IB) Investigator Dennis Seng was assigned to the case. The initial visit was conducted on 1/04/2022 from 1:00 p.m. – 2:15 p.m., and the LPA conducted a tour, briefly spoke with staff, and reviewed and obtained copies of pertinent records. IB Investigator Seng interviewed family members of R1 on 1/20/2022 and 3/2/2022; interviewed R1 on 1/20/2022; interviewed four staff members on 1/20/2022; interviewed three residents on 1/20/2022; and, reviewed medical records.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220103153627
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: OMNICARE II
FACILITY NUMBER: 565801460
VISIT DATE: 04/22/2022
NARRATIVE
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Regarding the allegation: Due to physical abuse, resident sustained fractured sternum
It was alleged that R1 sustained a fractured sternum due to physical abuse. The investigation revealed that staff believed they were transferring R1 appropriately and that they exercised caution in carrying for R1. Staff confirmed claims that R1 expressed pain after being transferred from the wheelchair to the bed on 12/17/2021. The investigation further noted that R1 was often transported by staff placing their arms underneath R1’s armpits, hugging R1 to their chest, and transferring R1 to the designated location. Staff noted that this was the method of transfer during the 12/17/2021 incident and when R1 was showered on 12/22/2021. Staff admitted that the bruising was noted on R1 on 12/23/2021. Staff noted that thereafter, they met with R1’s responsible party on 12/23/2021 and communicated that it due to R1’s fragility that the staff were unable to transfer R1 without a hoyer lift. However, R1 expressed chest pain on 12/28/2021 and 9-1-1 was called. R1 was hospitalized with multiple contusions and a fractured sternum.

The timeline of events and interviews confirmed that R1 sustained the bruising and fractured sternum while at the facility, yet there was insufficient evidence to support the claim that staff were physically abusive towards R1. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility staff improperly transferred resident


It was alleged that the facility staff improperly transferred R1, using only a one-person transfer versus a two-person transfer. The Physician’s Report, dated 11/08/2021, noted that R1 was deemed bedridden and did not have a history of skin breakdown. Whereas it was the preferred method of R1’s family to have a two-person transfer, there was no indication on the Physician’s Report – which was completed by an appropriately skilled professional – or any other documentation to confirm that R1 required a two-person transfer. Staff claimed that R1 was not deemed a two-person transfer; and, due to R1’s light weight, believed that they could successfully transfer R1 either with one or two staff persons. Although staff admitted that although R1 likely sustained bruising as a result of the transfers, there is insufficient evidence to support claims that R1 was improperly or incorrectly transferred. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6