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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801948
Report Date: 07/09/2021
Date Signed: 07/09/2021 04:50:57 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
01/31/2020 and conducted by Evaluator Kasandra Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200131091611
FACILITY NAME:NAVITA RESIDENCE EDGEMONT DRIVEFACILITY NUMBER:
565801948
ADMINISTRATOR:NICOLE ZANDERSFACILITY TYPE:
740
ADDRESS:1690 EDGEMONT DRIVETELEPHONE:
(805) 413-2455
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 6DATE:
07/09/2021
UNANNOUNCEDTIME BEGAN:
03:09 PM
MET WITH:Karthiga VijayakumarTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained multiple falls while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced complaint visit to deliver the findings for the above allegation. The LPA met with Assistant Administrator Karthiga Vijayaumar at 3:09 PM and explained the reason for the inspection. At approximately 3:10 PM, the LPA also spoke on the telephone with Administrator Praveen Syamala and explained the report findings and civil penalty that is being assessed today. Mr. Syamala was also advised that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).
The allegation, ‘Resident sustained multiple falls while in care’ alleges, as a result of neglect and lack of supervision, Resident #1 (R1) sustained multiple falls while in care and sustained multiple bruises to their face and body. On 03/04/2020, Community Care Licensing Division's (CCLD) Investigation's Branch (IB) Investigator Dennis Douglas conducted interviews with Administrator at the time, Nicole Zanders, Staff #1 (S1), Staff #2 (S2), and Resident #2 (R2). On 03/04/2020, Investigator Douglas also interviewed Witness #1 (W1) and Witness (#2), who are employees of the hospice care agency of which R1 was receiving services. Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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 5
Control Number 31-AS-20200131091611
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: NAVITA RESIDENCE EDGEMONT DRIVE
FACILITY NUMBER: 565801948
VISIT DATE: 07/09/2021
NARRATIVE
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Investigator Douglas attempted to interview Resident #3 (R3) at their current place of residence but was unable to due to their medical condition.

On 03/22/2020, Investigator Douglas conducted a telephone interview with Witness #3 (W3) who is a family member of another resident in the home. Investigator Douglas also obtained records from the hospital and the Ventura County Medical Examiner.

Interviews revealed R1 had three unwitnessed falls since moving into the facility. About a month after moving into the facility, R1 sustained their first fall in the bathroom on 08/28/2019. The plan of correction listed on the incident report the licensee submitted to CCLD indicated staff would provide stand by assistance at all times, and that staff would no longer allow R1 to use the bathroom by their self. However, R1 sustained their second fall on 01/28/2020 while being left unattended in the bathroom by S1. In that incident, R1 reportedly did not sustain any significant injuries and was not taken to the hospital. After this fall, there was a discussion with facility staff and the hospice nurse, and it was agreed R1 needed additional care, and staff would stay by R1’s side 24 hours a day. However, on 01/29/2020, R1 sustained a third unwitnessed fall of which R1 sustained a head injury and had to be taken to the hospital. R1 passed away the next day. It was reported by S1 that they were in the kitchen when R1 sustained the fall in their bedroom. S1 stated they presumed R1 was sleeping at this time. A review of hospital medical records revealed R1 arrived at the hospital on 01/29/2020, with a laceration and hematoma to the head, facial bruising, a skin tear to the left forearm, and multiple bruises in different ages to the upper and lower extremity. Based on this information, there is sufficient evidence to support the allegation of ‘Resident sustained multiple falls while in care.’ Therefore, the allegation is deemed substantiated at this time.

A $500 immediate civil penalty is being assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D). Exit interview conducted/ Appeal rights provided/ A copy of this report will be emailed.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 31-AS-20200131091611
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: NAVITA RESIDENCE EDGEMONT DRIVE
FACILITY NUMBER: 565801948
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2021
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
The requirement is not met as evidenced by:
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The administrator agrees to submit a written declaration that they have reviewed regulation 87468.1 and will comply with it at all times.

This written declaration shall be submitted to CCL by 07/13/2021.
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Based on interviews and record review, the licensee did not comply with the section cited above as one resident , (Resident #1) out of six residents sustained multiple falls while in care which poses an immediate health risk to residents in care.
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/31/2020 and conducted by Evaluator Kasandra Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200131091611

FACILITY NAME:NAVITA RESIDENCE EDGEMONT DRIVEFACILITY NUMBER:
565801948
ADMINISTRATOR:NICOLE ZANDERSFACILITY TYPE:
740
ADDRESS:1690 EDGEMONT DRIVETELEPHONE:
(805) 413-2455
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 6DATE:
07/09/2021
UNANNOUNCEDTIME BEGAN:
03:09 PM
MET WITH:Karthiga VijayakaumarTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff restrained resident
Facility staff caused bruising to resident
INVESTIGATION FINDINGS:
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On 03/04/2020, Community Care Licensing Division's (CCLD) Investigation's Branch (IB) Investigator Dennis Douglas conducted interviews with Administrator at the time, Nicole Zanders, Staff #1 (S1), Staff #2 (S2), and Resident #2 (R2). On 03/04/2020, Investigator Douglas also interviewed Witness #1 (W1) and Witness #2 who are employees of the hospice care agency of which R1 was receiving services. Investigator Douglas attempted to interview Resident #3 (R3) at their current place of residence but was unable to due to their medical condition. On 03/22/2020, Investigator Douglas conducted a telephone interview with Witness #3(W3) who is a family member of another resident in the home. Investigator Douglas also obtained records from the hospital and the Ventura County Medical Examiner.

Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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 5
Control Number 31-AS-20200131091611
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: NAVITA RESIDENCE EDGEMONT DRIVE
FACILITY NUMBER: 565801948
VISIT DATE: 07/09/2021
NARRATIVE
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The allegation of ‘Facility staff restrained resident’ alleges staff restrained Resident #1 (R1) so R1 would not wander into other resident’s bedrooms. During the course of the investigation, which included interviews and record review, there was no supportable evidence that staff were restraining R1 and no witnesses to this alleged occurrence. Therefore, the allegation of ‘Facility staff restrained resident’ is deemed unsubstantiated at this time.

The allegation of ‘Facility staff caused bruising to resident’ alleges R1 sustained bruising as a result of staff restraining R1. Based on information obtained during the investigation, there is insufficient evidence to support R1’s bruising was a result of being restrained by staff. Therefore, the allegation of ‘Facility staff caused bruising to resident’ is deemed unsubstantiated at this time.


Exit interview conducted with Ms. Vijayakumar. A copy of the report and appeal rights will be emailed.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5