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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801979
Report Date: 05/28/2024
Date Signed: 05/31/2024 04:58:31 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
05/04/2022 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20220504134133
FACILITY NAME:WELLNESS CARE SENIOR LIVINGFACILITY NUMBER:
565801979
ADMINISTRATOR:ALEIDA ALONSOFACILITY TYPE:
740
ADDRESS:158 ROCKAWAY ROADTELEPHONE:
(805) 649-5143
CITY:OAK VIEWSTATE: CAZIP CODE:
93022
CAPACITY:56CENSUS: 24DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Maria Hernandez- AdministratorTIME COMPLETED:
07:35 PM
ALLEGATION(S):
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Staff hit resident in care
Staff caused minor injuries to resident in care
Staff do not attend to residents in a timely manner
INVESTIGATION FINDINGS:
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On 05/28/24 at 10:25 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent unannounced complaint inspection at the facility. The LPA met with Administrator Maria Hernandez , explained the reason for the inspection and issued findings. Today, 05/31/24 the LPA conducted a subsequent visit to ammend the report and reissue the findings.
On 5/12/22, LPAs Rosales and Lopez conducted a physical plant tour with the Administrator beginning at 11:00 a.m., conducted interviews with facility staff and residents between 12:44 p.m. and 4:49 p.m., and at 3:50 p.m., the LPAs also began record review. On 3/15/24, between 10:45 a.m. and 4:00 p.m., LPA Cortez interviewed the Administrator, staff, residents, two (2) Individuals, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 04/09/24, between 10:30 a.m. and 4:45 p.m. LPA Cortez interviewed one (1) resident, two (2) staff, conducted file review and obtained copies of pertinent documents. On 05/28/24 LPA Cortez concuted two (2) interviews with residents family members. During today's visit the LPA conducted a file review, interviewed three (3) staff, residents family, and the administrator. Report will continue on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
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 8
Control Number 29-AS-20220504134133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WELLNESS CARE SENIOR LIVING
FACILITY NUMBER: 565801979
VISIT DATE: 05/28/2024
NARRATIVE
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(2ND PAGE CONTINUED...)

Staff hit resident in care
On the allegation that Staff hit resident in care; it is the concern of the reporting party (RP) that Resident #3 (R3) has complained against Staff #2 (S2) stating that S2 hit them. RP indicated the date is unknown. To investigate the allegations, interviews and file reviews were conducted. Interviews and file review confirmed that on 08/17/20 there had been an incident where R3 wanted to go into the living room and staff were mopping and had blocked off sections to prevent residents from entering and falling from wet floors and only R3 and two staff (S2, S3) were present during this incident. Interview conducted with R3 revealed that during that incident they were wrestle to the ground by S2 and S3, sustained superficial scrapes all over their body, was brought to their room and that S2 and S3 placed a bench in front of their room to prevent them from leaving. However, file review revealed that it was documented by (former) administrator Aly Alonzo that on 08/17/20 during a graveyard shift the living room was blocked by a bench because the floor was wet, and caregivers were mopping and sanitizing like they do every night. R3 got very agitated and angry because the caregivers told R3 to wait for the floor to dry, and R3 started screaming at them. Documentation went on to reveal that R3 started to move the bench, got a couple of scratches from the bench, went inside and almost fell. It was also documented that S2 and S3 helped R3 and R3 got very upset and started accusing them that they scratched them. Lastly, file review revealed that R3’s 2019 physicians reports stated that R3 was diagnosed with Dementia with behavioral disturbances. Interview with R3’s family revealed that R3 has a history of saying things that are not true and that they have no concerns of R3 ever being hit by staff. Interviews conducted with staff revealed that nine (9) of nine (9) staff interviewed regarding the above allegation have not observed or are not aware of any staff hitting residents. Furthermore, Interviews conducted with four (4) additional residents regarding the above allegation reflected that they denied being hit by staff or seen any staff hit residents.

Based on information gathered during the course of the investigation, the Department does not have sufficient evidence to determine staff hit resident in care. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Report will continue on LIC9099-C (3RD PAGE).
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20220504134133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WELLNESS CARE SENIOR LIVING
FACILITY NUMBER: 565801979
VISIT DATE: 05/28/2024
NARRATIVE
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(Page 3 continued...)

Staff caused minor injuries to resident in care
On the allegation that staff caused minor injuries to resident in care; it is the concern of the reporting party (RP) that Resident #4 (R4) sustained skin tears on their hands and staff do not know how R4 sustained the injuries. To investigate the allegation, interviews and file reviews were conducted. File review and interviews revealed that R4 is no longer at the facility. Staff interviews revealed that four (4) of seven (7) staff interviewed regarding the above allegation do not recall if R4 had sustained any skin tears on their hands. Staff interviews also revealed that when a resident is observed with a skin tear, their physician will get notified and staff will receive directions from the physician on how to proceed. Furthermore, interviews conducted with staff revealed that staff have not observed or are not aware of any staff hitting residents. File review revealed that in 2022 the department did not receive any reports regarding R4 sustaining skin tears. Lastly Physicians report for R4 dated 05/16/2022 reflected that R4 did not have any history of skin condition or breakdown.

Based on information gathered during the course of the investigation, the Department does not have sufficient evidence to determine staff caused minor injuries to resident in care. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Report will continue on LIC9099-C (4th page).
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
05/04/2022 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20220504134133

FACILITY NAME:WELLNESS CARE SENIOR LIVINGFACILITY NUMBER:
565801979
ADMINISTRATOR:ALEIDA ALONSOFACILITY TYPE:
740
ADDRESS:158 ROCKAWAY ROADTELEPHONE:
(805) 649-5143
CITY:OAK VIEWSTATE: CAZIP CODE:
93022
CAPACITY:56CENSUS: DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Maria HernandezTIME COMPLETED:
07:35 PM
ALLEGATION(S):
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9
Staff do not follow resident's hospice care plan
Staff did not report resident falls to appropriate parties
INVESTIGATION FINDINGS:
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On 05/28/24 at 10:25 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent unannounced complaint inspection at the facility. The LPA met with Administrator Maria Hernandez and explained the reason for the inspection and issued findings. Today, 05/31/24 the LPA conducted a subsequent visit to ammend the report and reissue findings.
On 5/12/22, LPAs Rosales and Lopez conducted a physical plant tour with the Administrator beginning at 11:00 a.m., conducted interviews with facility staff and residents between 12:44 p.m. and 4:49 p.m., and at 3:50 p.m., the LPAs also began record review. On 3/15/24, between 10:45 a.m. and 4:00 p.m., LPA Cortez interviewed the Administrator, staff, residents, two (2) Individuals, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 04/09/24, between 10:30 a.m. and 4:45 p.m. LPA Cortez interviewed one (1) resident, two (2) staff, conducted file review and obtained copies of pertinent documents. On 05/28/24 LPA Cortez concuted two (2) interviews with residents family members. During today's visit the LPA conducted a file review, interviewed three (3) staff, residents family, and the administrator. Report will continue on LIC9099-C (2nd page).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20220504134133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WELLNESS CARE SENIOR LIVING
FACILITY NUMBER: 565801979
VISIT DATE: 05/28/2024
NARRATIVE
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(2nd page continued...)

Staff do not follow resident's hospice care plan
On the allegation that staff do not follow resident’s hospice care plan; it is the reporting party’s concern that there is at least one resident (RP did not know the name) that is on hospice care and needs to be rotated every two hours, but staff are not rotating the resident. To investigate the complaint the LPA conducted file review and observations. File review revealed that Resident #5 (R5) is on hospice care, bedridden and needs to be repositioned and changed every two (2) hours. During today’s visit, the LPA was stationed in the living area outside of R5's bedroom from approximately 10:40 a.m. to 7:00 p.m. for approximately eight (8) hours. During this time the LPA observed a hospice nurse exit R5’s room after 10:40 a.m., observed a care staff enter R5’s room with their lunch tray at approximately 12:09 p.m. observed the administrator administer medication to R5 at 2:55 p.m., and observed a care staff enter R5’s room at approximately 04:09 p.m. File review indicated that R5 had received a bed check at 1:30 p.m. today by staff #4 (S4), however the LPA did not observed any staff enter R5’s room at 1:30 p.m. R5 went approximately four (4) hours from 12:09 p.m. to 4:09 p.m. without being rotated or changed. Interview with Administrator Maria reflected that residents who are on hospice and bed bound need to be repositioned and changed every two hours. Staff Interview with S4 revealed that the last time they repositioned S4 and checked their diaper was at approximately 12:00 p.m. when they went to deliver R5’s lunch and denies marking any paper with their initial including the room checklist that was provided to the LPA. Staff interviews revealed that residents have repositioned sheets in the residents bedrooms that staff mark with a check mark. File review and observations revealed that the repositioning sheets are not being documented by all staff.
Based on the information obtained, the allegation of staff do not follow resident's hospice care plan is deemed substantiated.

Staff did not report resident falls to appropriate parties
On the allegation that staff did not report resident falls to appropriate parties; it is the reporting party’s concern that the night shift staff will not document resident falls or report it to their responsible party. To investigate the complaint the LPA conducted interviews and conducted a file review. Resident interviews revealed that residents have experienced falls in the previous weeks. Resident interview and file review revealed that Resident #6 (R6) had a fall during the night in March. R6 stated they had a fall during the night on a Friday and reported it to staff on Monday.
Report will continue on LIC9099-C. (3rd page.)
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20220504134133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WELLNESS CARE SENIOR LIVING
FACILITY NUMBER: 565801979
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2024
Section Cited
CCR
87633(d)
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87633(d) Hospice Care of Terminally Ill Residents. The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times. This requirement is not met as evidenced by:
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Administrator has agreed to do the following: Submit a Plan of Action as to how residents' care plan will be followed and how they will ensured they are in compliance with regulation. Proof staff have received training on this plan to CCLD by 06/11/2024.
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Based on interview, file review, and observation, the licensee failed to follow the hospice care plan for R1, as R1 was not repositioned and changed every two (2) hours on 05/28/24 which poses a potential health and safety risk to residents in care.
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Type B
06/11/2024
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted … within seven days of the occurrence of any of the events specified ... (D) Any incident which threatens the welfare, safety or health of any resident ...
This requirement is not met as evidenced by:
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The administrator has agreed to do the following:1. Submit incident reports for R2’s fall for the record and notify responsible party. Submit to CCL no later than 06/11/24. 2. Submit a statement of understanding of regulation 87211(a)(1)(D) by POC due date.
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Based on record review, and interviews the licensee did not comply with the section cited above, as all of R2's incidents were not report to their responsible partty or licensing, which poses a potential health and safety risk for 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20220504134133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WELLNESS CARE SENIOR LIVING
FACILITY NUMBER: 565801979
VISIT DATE: 05/28/2024
NARRATIVE
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(Page 3 continued...)

Interview conducted with R6’s family member revealed that they had been notified of the fall by R6, and that they do not have any recollection or notification of facility staff notifying them of R6's fall. Furthermore, file review revealed that R6's fall was not reported to licensing.

Based on the information obtained, the allegation of staff did not report resident falls to appropriate parties is deemed substantiated.

The following deficiency was observed and cited from the California Code of Regulations. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20220504134133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WELLNESS CARE SENIOR LIVING
FACILITY NUMBER: 565801979
VISIT DATE: 05/28/2024
NARRATIVE
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(4TH page continued...)

Staff do not attend to residents in a timely manner
On the allegation that staff do not attend to residents in a timely manner; it is the concern of the reporting party (RP) that residents press their call light, but staff wait a while before attending to the residents. It was further reported that the facility is short on staff and sometimes turns off the resident call and does not attend to the resident. To investigate the allegation, interviews and observations were conducted. Interviews conducted with staff revealed that the facility has an alarm in the dining room that will make a loud sound when a resident pulls their cord from their room and staff responds right away to the resident’s call. Staff denied not responding to the call and being aware of other staff not responding to the call. Staff also revealed they are not aware of other staff resetting the alarm without responding to the residents. In addition, staff interviewed in 2022 revealed that during that time there were four (4) caregivers and one (1) MedTech during the PM shift. On 03/15/24 at 01:29 p.m. and on 04/09/24 at 12:59 p.m. LPA Cortez observed staff respond to residents call in their rooms within one (1) to three (3) minutes after they pulled their cord.

Based on information gathered during the course of the investigation, the Department does not have sufficient evidence to determine staff do not attend to residents in a timely manner. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8