565801529-2-16-2023-29-AS-DPEA-CPCS6K-20230224123605

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801529
Report Date: 02/16/2023
Date Signed: 02/16/2023 05:34:50 PM

Unsubstantiated

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

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210203094244

FACILITY NAME:	MOM'S PLACE 3		FACILITY NUMBER:	565801529
ADMINISTRATOR:	LINA BOLOTSKY		FACILITY TYPE:	740
ADDRESS:	975 VALLEY VISTA DR.		TELEPHONE:	(805) 389-8966
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 6	DATE:	02/16/2023
		UNANNOUNCED	TIME BEGAN:	04:48 PM
MET WITH:	Laila Kulungu		TIME COMPLETED:	05:43 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to lack of care and/or supervision, resident sustained injuries while in care
Staff did not assist resident with ADLs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA initially met with facility staff JR Perez and Romeo De Jesus. Administrator Laila Kulungu was contacted via telephone and arrived at the facility at 05:00PM. Entrance interview conducted.

On 02/04/2021, LPA conducted a virtual initial 10-day complaint visit. During the visit, LPA also conducted a telephone interview with Licensee Representative, Lina Bolotsky at 2:57PM. At 3:44PM, conducted a virtual tour of the facility, interviewed Resident #1 (R1) at 3:55PM, observed staff transferring R1 at 3:57PM, and the LPA requested copies of pertinent documents. During a subsequent complaint visit conducted on 02/07/2023, LPA interviewed staff at 10:47AM, 11:14AM, and 11:22AM, toured the facility with staff at 11:05AM, and attempted resident interviews. Throughout the course of the investigation, LPA reviewed pertinent documents. The following was then determined:
Report Continued on LIC 9099-C

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: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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 3

Control Number 29-AS-20210203094244

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 3	FACILITY NUMBER: 565801529
	VISIT DATE: 02/16/2023

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

Regarding the allegation “Due to lack of care and/or supervision, resident sustained injuries:”

It was alleged that Resident #1 (R1) called out for staff assistance, but the staff did not come to assist R1. R1 then attempted to get up on their own and R1 fell, resulting in a broken bone. Interview revealed that R1 had previously lived in another RCFE, where R1 had a history of falls. Record review revealed that R1 had moved into the facility on 07/11/2019. R1’s physician’s report indicated R1 had a diagnosis of Dementia, but that R1 was able to communicate their needs. When R1 moved into the facility, interview revealed that R1 did require standby assistance for transfers and R1 was aware they were unable to transfer without staff nearby. Physician’s report indicates that R1 was unable to independently transfer to and from bed. Staff interview revealed that R1 had a call button to use to request staff assistance. Interview and record review revealed that R1 was not on 1:1 care, nor did R1 require constant direct supervision.

On the evening of the fall, R1 had requested to watch television in their recliner chair in their private room. Staff interviewed stated the incident occurred in the evening, not during the night shift, so two (2) or three (3) staff would have been on duty at that time for the six (6) residents. Staff interviewed did not hear R1 verbally call for assistance, nor did staff hear the call button, although a staff was present in the next room over at that time. Additionally, R1 had a motion detector alarm in their room that would alert the staff if the resident moved about the room. Interview revealed that staff heard “a commotion,” responded to R1’s room promptly, and found R1 on the floor. Incident report indicates that on 07/15/2019 at around 7:30PM, R1 attempted to get up on their own using their walker when R1 lost their balance and fell, resulting in a fractured left femur and fractured right arm. Following the incident, the facility moved R1’s recliner chair to the common area in the living room, so staff could more easily observe R1 when watching television. Although R1 did fall, sustaining broken bones, based on interview and record review there is insufficient evidence to prove that the fall was a direct result of lack of care and/or supervision, therefore, the allegation that “due to lack of care and/or supervision, resident sustained injuries” is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff did not assist resident with ADLs:”

The complaint alleges that R1 was not assisted with a transfer when R1 called for assistance, resulting in R1 falling. Interview revealed that R1 did require assistance with transfers and was a 1-person transfer, as R1 was able to assist when standing up and transferring. When R1 initially moved in, R1 was able to dress and groom themselves, including shaving, could walk around the facility with their walker, feed themselves,

Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20210203094244

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 3	FACILITY NUMBER: 565801529
	VISIT DATE: 02/16/2023

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

and care for their own toileting needs. Staff interview revealed that when R1 was ready to get up or required assistance, R1 was to use their call button to request assistance. Staff stated that R1 was sometimes forgetful, so the facility utilized a motion detector in R1’s room to ensure R1’s ADL needs were met. LPA observed the residents in the home during the initial complaint inspection and again during the subsequent complaint inspection. All residents observed were dressed and groomed appropriately. LPA also observed staff assisting residents with feeding, transfers, and escorts during the visits. Based on interview and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “staff did not assist resident with ADLs” is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3