565801598-12-23-2021-29-AS-DPEA-C9ZPSL-20211224103431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801598
Report Date: 12/23/2021
Date Signed: 12/23/2021 02:09:35 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
08/06/2020 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20200806163338

FACILITY NAME:	ANGELS III		FACILITY NUMBER:	565801598
ADMINISTRATOR:	JOANN TRUPIANO		FACILITY TYPE:	740
ADDRESS:	3216 YARDLEY PLACE		TELEPHONE:	(805) 581-9422
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	0	CENSUS: 0	DATE:	12/23/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Joann Trupiano		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Lack of supervision resulting in resident sustaining a fall and fracture – Unsubstantiated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Zabel Chochian conducted a subsequent telephonic complaint visit to deliver the finding for the above allegation, as the facility was closed effective 11/02/2021. The complaint was initiated by LPA Kelly Dulek on 08/07/2020. LPA Chochian spoke with Administrator, Joann Trupiano and the reason for the call was explained. Following is a summary of the investigation:

Information was received that Resident #1 (R1) sustained an unwitnessed fall as a result of negligence by facility staff. During the initial visit on 08/07/2020 at approximately 3 p.m., LPA Dulek conducted a telephonic interview with Joann Trupiano, the facility administrator; and, a virtual physical plant tour was conducted at approximately 3:39 p.m. with facility designee, Tony Trupiano.

This case was referred to the Community Care Licensing Division’s Investigation’s Branch (IB) on 08/07/2020 and was assigned to Special Investigator, Harmin Sandhu, for a full investigation. (continue to LIC9099c)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

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-20200806163338

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: ANGELS III	FACILITY NUMBER: 565801598
	VISIT DATE: 12/23/2021

NARRATIVE

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The investigation consisted of an interview with resident #1’s (R1) responsible person (RP) on 09/24/2020, an interview with facility staff on 10/07/2020 at approximately 11:30 a.m. and an interview with the facility administrator on 10/07/2020 at approximately 11:50 a.m. The investigator attempted to interview R1, but R1 was unable to recall anything that had happened the five (5) months prior.

The interviews revealed that on 03/04/2020, at approximately 4:00 a.m., staff heard R1 yelling for help. The facility staff exited their room, went into R1’s room and observed R1 laying on the floor in the bathroom. The staff contacted 9-1-1 and the administrator immediately. However, after the paramedics arrived and assessed R1, R1 refused to go with paramedics to the hospital. The facility staff also contacted R1’s responsible person (RP), who spoke to and received confirmation from the paramedics that R1 was refusing transportation to the hospital. Since R1 appeared stable, the paramedics left.

On 03/05/2020, the facility staff contacted the RP, notifying them that R1 was complaining of pain in the left rib area. The RP arrived at the facility and took R1 to the hospital for an assessment. R1 was diagnosed with three (3) fractured ribs and a head contusion. It was reported that staff did what they could upon discovering R1. R1’s responsible person did not have any complaints regarding R1’s care or supervision and stated that staff responded immediately by calling 9-1-1 upon the discovery that R1 had fallen.

Facility records were reviewed, which reflected that R1 was not a fall risk, was mostly independent with activities of daily living, able to articulate their wants and needs, able to ambulate without assistance, and able to use the bathroom without assistance. Information gathered revealed that on 03/4/2020, R1 went to the bathroom unassisted and sustained a fall. R1 did not alert staff that they wanted to use the bathroom, since R1 was able to ambulate and use the bathroom without staff assistance.

Based on interviews conducted and records reviewed, the department does not have sufficient information to support the allegation. Therefore, the allegation “Lack of supervision resulting in resident sustaining a fall and fracture” is deemed unsubstantiated at this time.

Exit interview conducted. Copy of report and appeal rights provided to administrator via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
08/06/2020 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20200806163338

FACILITY NAME:	ANGELS III		FACILITY NUMBER:	565801598
ADMINISTRATOR:	JOANN TRUPIANO		FACILITY TYPE:	740
ADDRESS:	3216 YARDLEY PLACE		TELEPHONE:	(805) 581-9422
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	0	CENSUS: 0	DATE:	12/23/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Joann Trupiano		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility did not refund residents preadmission fees

INVESTIGATION FINDINGS:

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A subsequent telephonic complaint contact was made to deliver the finding for the above allegation, as the facility was closed effective 11/02/2021. Reason for the call was explained to Mrs. Trupiano. Complaint was initiated by Licensing Program Analyst (LPA) Kelly Dulek on 08/07/2020 at approximately 3pm, allegation was discussed with administrator; copy of R1’s admission agreement and invoice/receipt were requested. On 09/17/2020 at approximately 2pm, LPA Chochian interviewed reporting party. R1 moved into the facility on 02/15/2020, sustained a fall on 03/05/2020 and was transferred to Simi Hospital. R1 did not return back to facility and all belongings were removed from facility on 3/6/2020. R1 paid $1500 pre-admission/community fee + $2000 for the remaining month of 2/2020. In addition, R1 paid $5000 for the month of 03/2020. Administrator stated, R1 was Issued a refund of $3486 when belongings were removed; the community fee was not refunded. Records reviewed and interviews conducted confirmed R1 was not issued the correct refund amount. Based on the interviews conducted and records reviewed allegation “Facility did not refund resident's preadmission fees” is deemed Substantiated. Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiency is cited (Refer to LIC LIC9099-D). Exit interview conducted. Copy of report and appeal rights provided via email.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20200806163338

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: ANGELS III	FACILITY NUMBER: 565801598
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/23/2021 Section Cited HSC 1569.651(h)(2)	1 2 3 4 5 6 7	Preadmission fee or deposit for elderly at residential care facilities; written statement describing costs and stating whether fee is refundable; conditions for refund; refund rate schedules.(h)Unless subdivision (g) applies, preadmission fees in excess of five hundred dollars ($500) shall be refunded according to the following: (2) If the resident leaves the	1 2 3 4 5 6 7	Facility closed effective November 2, 2021. Prior to closure of the facility Administrator provided a refund of the pre-admission fee to R1/R1's responsible person.
	8 9 10 11 12 13 14	facility for any reason during the first month of residency, the resident shall be entitled to a refund.... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited as R1 was not refunded the "pre-admission fee".	8 9 10 11 12 13 14
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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: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

LIC9099 (FAS) - (06/04)

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