565801949-3-4-2024-29-AS-TCAA-D32TZW-20240304141100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801949
Report Date: 03/04/2024
Date Signed: 03/04/2024 02:11:10 PM

Document Has Been Signed on 03/04/2024 02:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	APPLEGATE @ DORADO		FACILITY NUMBER:	565801949
ADMINISTRATOR:	EMMA CARMONA		FACILITY TYPE:	740
ADDRESS:	1630 EL DORADO DRIVE		TELEPHONE:	(805) 379-1055
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY:	6	CENSUS: 6	DATE:	03/04/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Emma Carmona		TIME COMPLETED:	02:40 PM

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On 3/4/2024, Licensing Program Analyst (LPA) Teresa Camara met with facility administrator Emma Carmona for a Case Management visit to issue a civil penalty per Health & Safety (H&S) Code §1569.49(f).

On June 21, 2019, the Department received an Unusual Incident Report regarding resident (R1). The report indicated R1 was left unattended in the bathroom and while unattended, R1 fell. The fall resulted in injuries and subsequent hospitalization. To investigate, the Department conducted visits to this facility on June 24, 2019, September 18, 2019, and February 25, 2020.

On February 25, 2020, the Department concluded their investigation, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, Section 87464(f)(4) Basic Services, due to the staff failing to provide adequate supervision, as R1 was left unattended, suffered a fall, a right femur fracture and two (2) right rib fractures.

The investigation revealed that on June 21, 2019, at approximately 6:30 a.m., R1 was assisted to the bathroom by staff (S1). R1 was left unattended while S1 walked out of the bathroom, into R1’s closet to obtain a change of clothes and a new pull-up adult brief. S1 overheard a noise and upon re-entering R1’s bathroom, observed R1 lying on the bathroom floor on their right side. S1 informed facility management, R1’s responsible party, and R1’s hospice agency of the fall. It was decided R1 required emergency services and 9-1-1 was called. Per hospital records, R1 suffered a right femur fracture and two (2) right rib fractures. R1 elected to not have surgery and was discharged back to the facility on hospice care on June 21, 2019, at 11:42 a.m.

(continued on 809-C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: APPLEGATE @ DORADO	FACILITY NUMBER: 565801949
	VISIT DATE: 03/04/2024

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(continued from 809)

On February 25, 2020, an immediate civil penalty of $500 was assessed as a result of this violation. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(f).

The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. Per Welfare and Institutions Code §15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility’s failure to provide care and supervision to R1 on June 21, 2019, as S1 left R1 unattended in the bathroom. R1 was deemed high risk for falls and required a one-person assist. R1 sustained two (2) broken ribs, a right femur fracture, and experienced severe pain.

Today, 3/4/2024, the Department is issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on February 25, 2020, the amount of the civil penalty issued is reduced to $9,500.

A copy of the LIC 421D was given to the administrator and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. The administrator's signature on this report acknowledges receipt of the Appeal Rights, found on page two (2) of LIC 421D.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC809 (FAS) - (06/04)

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