565801947-2-24-2023-29-AS-KBUY-CPGTDS-20230228133845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801947
Report Date: 02/24/2023
Date Signed: 02/24/2023 01:23:51 PM

Substantiated

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
01/28/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20220128151852

FACILITY NAME:	ENDURING OAKS ASSISTED LIVING, LLC		FACILITY NUMBER:	565801947
ADMINISTRATOR:	MIRVAT YACOUB		FACILITY TYPE:	740
ADDRESS:	4264 COLIBRI COURT		TELEPHONE:	(805) 530-3818
CITY:	MOORPARK	STATE: CA	ZIP CODE:	93021
CAPACITY:	6	CENSUS: 5	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Mirvat Yacoub		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident not being provided adequate care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Administrator Mirvat Yacoub. Entrance interview.

Concerns were that resident #1 (R1) is not being provided adequate care as R1’s pressure injuries are not getting better as staff have not been repositioning and changing R1 as often as needed.

On 2/2/22 starting at 11:04 am interviews were conducted with staff, resident family member, and residents. Interview with staff revealed that R1 is being repositioned every 2 hours from 6 am to 10 pm. Staff sets an alarm at 2 am to turn R1. A review of R1’s records on 2/2/22 starting at 11:38 am revealed a physician’s order dated 12/29/21 stating R1’s pressure injury to R Hip was worsening.

Report Continued on LIC 9099C...

Substantiated

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: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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-20220128151852

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: ENDURING OAKS ASSISTED LIVING, LLC	FACILITY NUMBER: 565801947
	VISIT DATE: 02/24/2023

NARRATIVE

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Report Continued from LIC 9099...

On 1/11/22 R1 had an initial evaluation with Wound Pros Wound Care Experts which recommended R1 be turned and repositioned every hour while sitting and every 2 hours while in bed as well as to keep the area clean and dry. R1’s January 2022 Re-Positioning records revealed that it was documented that R1 was only repositioned 1/1/22 to 1/9/22, 1/16/22, 1/18/22, 1/24/22 to 1/31/22 every 2 hours from 6 am to 10 pm, and was not repositioned overnight from 10pm to 6am. Re-Positioning records also indicate R1 was only repositioned 1/10/22 to 1/15/22, 1/17/22, 1/19/22 to 1/23/22 every 2 hours from 6 am to 8 pm, and was not repositioned overnight from 8pm to 6am. Based on the information obtained during the course of the investigation, the allegation that Resident not being provided adequate care is substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview conducted. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220128151852

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: ENDURING OAKS ASSISTED LIVING, LLC	FACILITY NUMBER: 565801947
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 03/01/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator has agreed to submit a Statement of Understanding explaining the steps the facility will follow to avoid similar issues from happening again regarding meeting basic care needs of the residents and submit to CCL by 03/01/2023.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as R1 was not being repositioned as recommended which posed a potential health and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

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