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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801762
Report Date: 09/08/2020
Date Signed: 09/08/2020 03:58:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:OMNICARE IIIFACILITY NUMBER:
565801762
ADMINISTRATOR:KINGA KOZDRONFACILITY TYPE:
740
ADDRESS:1446 SUFFOLK AVENUETELEPHONE:
(805) 496-9592
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
09/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Kinga KozdronTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Desaree Perera initiated Case Management - Incident visit. The purpose of this visit is to follow up on a Unusual Incident/Injury Report (UIR) submitted to the department on 09/05/2020. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, todays visit was conducted via FaceTime with administrator Kinga Kozdron at 2:30pm.
It was reported that on 09/01/2020, staff noticed redness on Resident #1 (R1) coccyx area and initiated pressure injury prevention measures. Per the report, on 09/03/2020 staff noticed skin breakdown in the area and on the evening of 09/04/2020 per the administrator the pressure injury appeared to be "unstageable" with purple and red discoloration. On 09/05/2020, administrator reached out to the responsible party of R1 and requested for a skilled medical professional to evaluate resident. A physicians order for hospice services were obtained on 09/08/2020.
A telephone interview was conducted with administrator on 09/08/2020 at 9:50am to gather additional information regarding the incident and also requested documentation pertinent to the incident. During today's virtual visit, LPA conducted a tour of the physical plant at 2:32pm and conducted an additional interview with administrator at 2:45pm. Prior to issuing final licensing report, it has been determined that further investigation is needed at this time.

Exit interview conducted via telephone and report was emailed for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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