565801892-5-29-2025-29-AS-KBUY-DJ63SB-20250630183005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801892
Report Date: 05/29/2025
Date Signed: 05/29/2025 02:46:44 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
11/20/2024 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20241120161811

FACILITY NAME:	FILLMORE COUNTRY CLUB		FACILITY NUMBER:	565801892
ADMINISTRATOR:	LUIS GONZALEZ		FACILITY TYPE:	740
ADDRESS:	827 RIVER STREET		TELEPHONE:	(805) 524-5080
CITY:	FILLMORE	STATE: CA	ZIP CODE:	93015
CAPACITY:	66	CENSUS: 29	DATE:	05/29/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Rose Gonzalez - Assistant Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Due to neglect and/or abuse, resident sustained fractures in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Rose Gonzalez and explained the reason for the visit.
On 11/20/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding injuries sustained by a resident at the Fillmore Country Club facility. It was reported that Resident #1 (R1) sustained multiple unexplained injuries while at the facility, including a fracture to the wrist. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Douglas.
On 11/21/2024, from 1:25pm to 3:30pm, Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA Balisi met with assistant administrator Rose Gonzalez and explained the reason for the visit. At approximately 1:30pm, the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

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-20241120161811

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: FILLMORE COUNTRY CLUB	FACILITY NUMBER: 565801892
	VISIT DATE: 05/29/2025

NARRATIVE

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No immediate health and safety concerns were observed during the visit. The LPA determined further investigation was needed prior to issuing findings.On 12/04/2024, at approximately 4:40pm, Investigator Douglas conducted an interview with Kaiser Permanente Woodland Hills hospital staff; on 01/14/2025, at approximately 3:25pm, with R1’s resident representative; and on 02/27/2025, from approximately 12:45pm to 2:00pm, with assistant administrator, staff, and attempted to interview R1 (who was unable to articulate a statement or be interviewed). In addition, the investigator reviewed Kaiser Permanente Woodland Hills medical reports, and facility documents related to the investigation including incident reports, progress notes, and needs and services plan.

Facility file documents reviewed revealed R1 was admitted to the facility on 06/25/2022. R1’s diagnosis included dementia, hypertension, hyperlipidemia and atherosclerosis of aorta. The facility progress notes reviewed did not indicate R1 sustained any falls. The progress notes indicated on 11/08/2024, staff found R1 pulling self near the bars (bed rail); on 11/13/2024, R1 was found two times pulling self in between bars; on 11/16/2024, staff noticed R1’s wrist a little swollen, R1 said it did not hurt, R1’s resident representative said they noticed it last night and R1 crying in pain. On 11/17/2024, staff moved R1 over in bed, R1 was “super close” to the bar; on 11/21/2024, staff put pillow in between bar and R1’s arm, R1 was grabbing on bar and pulling self to side. R1’s Needs and Services Plan, updated 06/10/2024, noted R1 had dementia, wheelchair bound, can self-propel in wheelchair, verbally communicates needs, max care, needs assistance with all activities of daily living, shower schedule twice per week, R1’s resident representative manages R1’s medications, laundry and housekeeping, caregivers will notify R1’s resident representative of any pain or symptoms R1 may be having and notify of any changes and MD if needed.

The Department’s investigation revealed R1 sustained several significant injuries at the facility over the period of 11/07/2023 – 11/20/2024, which included a bruised clavicle, fractured shoulder, and fractured wrist. Copies of medical reports documented the injuries R1 sustained during this period. A review of the unusual incident reports for R1 revealed that the facility submitted reports on 11/08/2023, 01/03/2024, and 11/21/2024 for R1’s unexplained injuries. Per the Kaiser Permanente Woodland Hills medical reports reviewed, the following was revealed related to the incident reports. On 11/07/2023, it was noted that R1 was presented to urgent care by R1’s resident representative with neck pain they had been experiencing for the last six days. Bruising was observed on R1’s left clavicle area. It was determined R1 sustained a “bruised clavicle.”

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20241120161811

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: FILLMORE COUNTRY CLUB	FACILITY NUMBER: 565801892
	VISIT DATE: 05/29/2025

NARRATIVE

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R1 disclosed that R1 experienced an unwitnessed fall at the facility resulting in the injury. However, staff members were unaware of any fall and stated they never discovered R1 on the floor prior to the discovery of R1’s injury. R1 also did not complain of pain. Staff interviewed noted R1 sometimes said they “fell” just prior to their family member visiting, but it was not true and R1 had not fallen.
On 12/29/2023, it was then reported that R1 was again presented to the urgent care with left shoulder pain R1 claimed had been experiencing the last three days. It was discovered R1 had sustained a fracture to the right humeral head articular (shoulder). It was noted as a “probable fall.” However, staff members again disclosed they never observed R1 on the floor prior to that injury. R1 also did not complain of any pain. Staff members explained R1 is not mobile and would not be able to lift themselves up off the floor on their own. On 11/20/2024, R1 was again presented to urgent care (by R1’s resident representative), complaining of left wrist pain R1 estimated had been bothering R1 the last five days. Following X- rays, it was discovered R1 sustained a left wrist fracture. However, R1 did not disclose any recent falls. Staff members also claimed those five days prior, there was no report that R1 had experienced a fall at the facility. R1 also had not complained of any pain. It was noted by staff that, on 11/16/2024 (four days prior to R1’s injury), staff observed R1’s wrist was “a little swollen.” However, R1 did not complain of pain. When R1 was asked by staff what happened, R1 indicated it happened the previous night when R1 was dressing self.
The Department’s interviews conducted revealed that R1’s resident representative did not believe Fillmore Country Club staff members were physically abusing R1. However, they believed the staff were aware of R1’s injuries and were simply not reporting them. Facility staff were interviewed and denied physically abusing R1 or witnessing any abuse. Staff explained they believed R1 may have sustained injuries as a result of consistently wedging themself between the bed and a bed rail attached to the mattress. Staff also explained R1 would bang on the wall next to their bed instead of using their pendant when they needed assistance. During the investigation, Investigator Douglas attempted to conduct an interview with R1, however, R1 was unable to articulate a statement.
Based on all the information obtained during the course of the investigation, R1 sustained several significant unexplained injuries (bruised clavicle, fractured shoulder, and fractured wrist) at the facility, however the Department’s investigation did not provide sufficient evidence to determine neglect/lack of care and supervision or physical abuse. Therefore, the allegation of “Neglect/Lack of Care and Supervision Facility resident sustained significant unexplained injuries” is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC9099 (FAS) - (06/04)

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