565801527-8-31-2021-29-AS-KHEN-C79UZH-20210927160133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801527
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:31:51 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
02/03/2021 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20210203140034

FACILITY NAME:	MOM'S PLACE 1		FACILITY NUMBER:	565801527
ADMINISTRATOR:	DMITRY BOLOTSKY		FACILITY TYPE:	740
ADDRESS:	4 MANSFIELD LANE		TELEPHONE:	(805) 383-9896
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 5	DATE:	08/31/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lina Bolotsky		TIME COMPLETED:	01:58 PM

ALLEGATION(S):

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Questionable death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced complaint visit. The purpose of the visit is to conclude an investigation initiated by LPA Dulek on 02/04/2021. LPA Dulek met with Licensee Lina Bolotsky. Entrance interview conducted.

On 02/03/2021, the Department received a complaint alleging a questionable death of Resident #1 (R1). This allegation was previously investigated by CCLD Investigations Branch (CCLD IB) Investigator Robert Kujawa after the facility submitted a death report for R1 on 06/03/2019.

Due to the situation surrounding Coronavirus 2019 (COVID-19) and to implement mitigation measures, LPA Dulek conducted a virtual initial 10-day visit on 02/04/2021; at which time, LPA conducted an interview with the Administrator at 2:57PM and virtually toured the facility at 4:34PM to ensure health and safety of residents. During the investigation, Investigator Kujawa reviewed R1’s medical records and other relevant documents, as

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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-20210203140034

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: MOM'S PLACE 1	FACILITY NUMBER: 565801527
	VISIT DATE: 08/31/2021

NARRATIVE

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well as a copy of the police report. Additionally, Investigator Kujawa interviewed facility staff on 12/10/2019 and 12/17/2019, and residents on 12/10/2019.

Information gathered revealed that R1 had limited mobility, limited verbal abilities, and had a diagnosis of dementia. R1 had a motion alarm, which triggered when R1 got out of bed. In addition, R1 had a metal pole affixed to the ceiling and the floor next to R1’s bed. The pole was installed in 2010 by R1’s Physical Therapist and was approved by CCL to assist R1 in getting in and out of bed. Interviews revealed facility staff check on residents throughout the night. On the night of 05/29/2019, R1 had been observed to be sleeping safely during the 3:00AM check. However, when staff entered the room at 7:30AM, staff found R1 deceased. Staff interviews revealed on the night of the incident, R1’s out of bed alarm did not engage. Motion alarms were tested and were functional at the time of CCL’s visit. Sheriff’s Department found no signs of a crime; first responders indicated it appeared as if R1 had rolled off the bed. Coroner’s report findings were consistent with an accidental death. Based on all information gathered, the Department does not have sufficient evidence to determine neglect/lack of care and supervision to R1 resulted in R1’s death at this time. Therefore, the above allegation “Questionable Death” is deemed UNSUBSTANATIED at this time.

Exit interview conducted. No citations issued. A copy of this report was provided to the Licensee via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC9099 (FAS) - (06/04)

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