565801871-10-22-2021-29-AS-DPEA-CGQMAH-20220727092623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801871
Report Date: 10/22/2021
Date Signed: 10/22/2021 01:19:37 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
10/26/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20201026173838

FACILITY NAME:	SIMI HILLS HOME CARE CENTER, LLC		FACILITY NUMBER:	565801871
ADMINISTRATOR:	LIDIA MEDINA		FACILITY TYPE:	740
ADDRESS:	2062 VERA COURT		TELEPHONE:	(818) 577-8231
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 1	DATE:	10/22/2021
		UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Lidia Medina - Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff not following resident's dietary plan.

Resident's personal items are inaccessible.

Staff neglected resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegations. Upon arrival LPA met with Lidia and explained the reason for the visit.

During the course of the investigation, LPA conducted a physical plant tour 09/09/2021 as well as interviewed Administrator, staff and residents. LPA also gathered and reviewed facility documentation pertinent to the allegations. LPA also interviewed parties with knowledge of the situation.

It was alleged that staff are not following resident's dietary plan. LPA interview with staff revealed that Resident 1 (R1) did not have a dietary plan ordered by a doctor or dietician, but they were diabetic. Staff ensured R1 consumed food items with little or no sugar and high protein. R1 was consistently offered fruits and vegetables , but they were not highly preferred by R1. LPA interview with the spouse of R1 revealed they never had concerns of the staff not offering a healthy and balanced diet for R1.
(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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-20201026173838

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: SIMI HILLS HOME CARE CENTER, LLC	FACILITY NUMBER: 565801871
	VISIT DATE: 10/22/2021

NARRATIVE

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Continued from 9099
The spouse stated staff would express concern whenever the spouse visited and occasionally brought candy and fast food for R1. LPA records review revealed that there was no dietary plan on file for R1. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff are not following resident's dietary plan. Therefore, this allegation has been UNSUBSTANTIATED at this time.

It was alleged that Resident's personal items are inaccessible. LPA interview with staff revealed that R1 was given (2) movable side tables , which R1 placed various items on that they liked to keep in reach, including their phone which was always attached to a 15 foot long charging cable. LPA's interview with spouse of R1 revealed R1 never expressed any concerns of any of their personal items being inaccessible and they also stated that whenever they would pay R1 a visit , they observed all of R1's personal items always within reach including R1's phone charger. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that Resident's personal items are inaccessible. Therefore, this allegation has been UNSUBSTANTIATED at this time.

It was alleged that Staff neglected resident, LPA interview with the spouse of R1 revealed that R1 never expressed any concerns of not being serviced, or being checked on by staff.The spouse stated that R1 enjoyed their time at the facility , but as their health began to decline R1 had become more demanding. R1's spouse stated they had no issues with the quality of service the staff provided to R1. LPAs interview with Staff 1 (S1) , who was one of the main caregivers who interacted with R1, revealed that at the time R1 was in their care, there was only (2) residents total, R1 and Resident 2 (R2). R2 had dialysis appointments 3 days out of the week so the majority of the time, R1 had the full attention of S1. S1 stated that R1 had a routine of checking on R1 at least every hour, but R1 would constantly call for S1 and either needed assistance or R1 just wanted to have a conversation. LPAs interview with other parties with knowledge of the situation stated they believe there is a sufficient amount of staff to provide care for the residents and they do not have any immediate or potential concerns of being neglected by staff. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that Staff neglected resident. Therefore this allegation has been UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

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