565801532-2-16-2023-29-AS-DPEA-CPCS25-20230224122858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801532
Report Date: 02/16/2023
Date Signed: 02/16/2023 11:31:53 AM

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
03/25/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20220325091634

FACILITY NAME:	NORMA J'S HOME FOR THE ELDERLY, THE		FACILITY NUMBER:	565801532
ADMINISTRATOR:	LORETTA LOUISE TIEDE		FACILITY TYPE:	740
ADDRESS:	142 W. COLUMBIA ROAD		TELEPHONE:	(818) 422-7667
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	02/16/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Susana Vincecruz		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff inappropriately touched resident
Staff made inappropriate comments towards resident
Facility serving food that is not of quality

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with staff Susana and explained the reason for the visit as the Administrator was unavailable. Entrance interview.

On 03/24/2022, the Department received a complaint regarding an allegation of sexual abuse – staff inappropriately touched resident. It was alleged that Staff #1 (S1) sexually abused Resident #1 (R1) by inappropriately touching R1’s breasts and vaginal area. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real.

Report Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
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)

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Control Number 29-AS-20220325091634

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: NORMA J'S HOME FOR THE ELDERLY, THE	FACILITY NUMBER: 565801532
	VISIT DATE: 02/16/2023

NARRATIVE

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Report Continued from LIC 9099...

On 03/25/2022, from 11:00am to 12:55pm, Licensing Program Analyst (LPA), Martha Guzman-Chavez conducted an initial complaint visit for the above allegation. The LPA met with Licensee Representative, Loretta Tiede and explained the reason for the visit. Additionally, the LPA interviewed the Licensee Representative at 11:25am and obtained copies of pertinent documents relevant to the investigation. On 08/09/2022, between 11:21am to 12:13pm, LPA Arroyo interviewed the Administrator, one staff, five residents, and observed the kitchen and food supply at 11:49am.

On 03/28/2022, Investigator Real conducted an interview with R1’s resident representative; on 04/08/2022, with R1; and on 05/12/2022, with residents, Staff #1 (S1) and Staff #2 (S2). Additionally, Investigator Real reviewed facility file documents related to R1.

A review of R1’s Appraisal/Needs and Services Plan, dated 01/27/2022, noted R1 is very difficult, upset and confused. R1’s physician report, dated 01/28/2022, listed R1’s primary diagnosis as right distal femur fracture. R1 was identified as being confused/disoriented yet able to follow instruction and communicate their needs. The report indicated R1 was not able to bathe, dress/groom, feed, or take care of their toileting needs. The resident appraisal, dated 01/31/2022, noted R1 as having a bad hurting hip and is in pain and confused. R1’s ambulatory status was listed as non-ambulatory and needed help with bathing, eating, and toileting. A notation indicated R1’s medication was needed and R1’s resident representative indicated they would get them.

R1 moved into the facility on 01/28/2022. Prior to moving into the facility R1 had been in the hospital as a result of a fall at home. R1 sustained a femur fracture as a result of the fall. After being discharged from the hospital R1 went to the facility where R1 stayed for six days. On 02/03/2022, R1’s resident representative transferred R1 out of the facility as R1 was not happy at the facility.

Report Continued on LIC 9099C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
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)

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Control Number 29-AS-20220325091634

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: NORMA J'S HOME FOR THE ELDERLY, THE	FACILITY NUMBER: 565801532
	VISIT DATE: 02/16/2023

NARRATIVE

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Report Continued from LIC 9099C...

Information obtained from the investigator’s interviews revealed R1 denied any sexual abuse by S1 or anyone else in the facility. R1 was in a lot of pain due to a recent fall that resulted in a fractured femur and did not want to me moved or touched. S1 was never alone with R1 and S1 always had another staff present when S1 was helping to reposition R1. R1 did not like being touched by S1 because R1 felt S1 was rough with them. R1 did not sustain any injuries by S1 or anyone else in the facility. R1’s resident representative reported R1 was in pain and R1 complained that S1 touched R1 “all over”. R1 did not disclose any specific location where they were touched. R1 never reported being touched on breast, vagina, or buttocks in a sexual manner. R1’s resident representative denied witnessing any abuse or neglect while visiting R1 in the facility. The residents interviewed did not report any problems, complaints, or abuse (sexual or physical). No residents reported S1 was rough when helping them move. S2 reported they were R1’s primary caregiver and S1 was never alone with R1. S2 changed R1’s diapers and bathed R1. S1 assisted by helping move R1 only when needed during diaper changes or when asked by S2. R1 was in a lot of pain due to the fractured leg and was very difficult and confused. R1 frequently complained of pain and did not want anyone to touch them. S1 denied the allegation and stated they only touched or moved R1 when assisting S2 as S2 was the primary caregiver for R1. S1 recalled R1 complained a lot and was in a lot of pain when R1 came into the facility after being discharged from the hospital. S1 tried to say nice things to R1 to make R1 feel better, but it was not helpful and R1 was confrontational. The information obtained during the investigation did not sufficiently support the allegation, therefore, the allegation “Sexual Abuse - Staff inappropriately touched resident” is deemed Unsubstantiated at this time.

It was also alleged that staff made inappropriate comments towards resident. It was reported that S1 was calling R1 names such as ‘honey’ and ‘baby’ while living at the facility. Interviews conducted revealed R1 had been discharged from the hospital shortly before being admitted to the facility on 01/28/2022. Also, record review indicated R1’s primary diagnosis was right distal femur fracture. Due to the pain R1 was having while at the facility, S1 tried to say nice things to R1 to make R1 feel better; however, that did not help and R1 was confrontational.

Report Continued on LIC 9099C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
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 4

Control Number 29-AS-20220325091634

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: NORMA J'S HOME FOR THE ELDERLY, THE	FACILITY NUMBER: 565801532
	VISIT DATE: 02/16/2023

NARRATIVE

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Report Continued from LIC 9099C...

Correspondingly, interviews conducted with R1 revealed S1 was never in R1’s room by themselves. R1 also added that S1 did not say anything of a sexual nature to R1 while living at the facility. Interviews conducted with residents revealed that none of the residents have ever reported any problems or complaints amongst themselves regarding S1 or anyone else. Furthermore, residents stated they have not observed S1 harm or bother any of the residents in the facility. S2 reported S1 helps out mainly to reposition residents and S2 is always present as they work as a team. Based on the evidence gathered through interviews with residents, staff, and Administrator, there is insufficient evidence to support the allegation, ‘staff made inappropriate comments towards resident.’ Therefore, this allegation is deemed Unsubstantiated at this time.

It was further alleged that facility is serving food that is not of quality. It was reported that food served at the facility was bad. During the visit on 08/09/2022, the LPA observed the kitchen and food supply. The facility had a variety of food including fruits, vegetables, milk, meats, eggs, and bread. Interviews conducted revealed facility staff go grocery shopping every Saturday. On Friday’s the staff clean out the refrigerator to make sure the food is still good and to make space for the new groceries that will be brought the following day. Items purchased every week usually consist of foods that residents enjoy as well as other items necessary to follow a certain dietary need. Although the facility does not have a specific menu to follow, the staff cooks every day and make sure it is something all residents will enjoy since it varies depending on each resident’s wants and needs. Furthermore, residents stated liking the food prepared for them and staff making good home cooked meals every day. Based on LPA observation and interviews conducted with the staff, residents, and Administrator, there is insufficient evidence to support the allegation, ‘facility serving food that is not of quality.’ Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview. . Report was reviewed with staff Susana and a copy of report was given.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
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)

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