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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802411
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:41:12 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
01/04/2022 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20220104110534
FACILITY NAME:ANITA'S CARE VILLAFACILITY NUMBER:
565802411
ADMINISTRATOR:SHAFFER, JENNIFERFACILITY TYPE:
740
ADDRESS:521 LOUIS DRIVETELEPHONE:
(805) 716-3633
CITY:NEWBURY PARKSTATE: CAZIP CODE:
91320
CAPACITY:6CENSUS: 3DATE:
06/24/2022
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Jennifer ShafferTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident developed pressure injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 1/13/2022 by LPA Guzman Chavez. On today’s visit, LPA Arroyo met with Administrator, Jennifer Shaffer. Entrance interview conducted.

During the initial visit on 1/13/2022, at 1:35 p.m., LPA Guzman Chavez toured the facility, conducted interviews with the administrator, two staff, one resident, and obtained copies of pertinent documents. Medical Records were also obtained during the course of the investigation.

It was alleged that “resident developed pressure injuries while in care”. It was reported that Resident #1 (R1) had 2 open wounds and a scab when admitted to the facility, and later on developed new wounds.

...Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
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 4
Control Number 29-AS-20220104110534
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: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411
VISIT DATE: 06/24/2022
NARRATIVE
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...Continued from LIC 9099...

Information obtained revealed R1 was admitted to the facility on 12/02/21 as non-ambulatory, requiring continuous bed care in assisting with repositioning, and required assistance of another person with activities of daily living (ADL’s) including bathing, dressing, and toileting. Record review of R1’s Resident Appraisal stated R1 was unable to move lower extremities, needed help with transfers, legs were swollen, and noted R1 to have a sore on their heel. Before admission to the facility, on 11/27/2021, R1 was assessed by DaranCare Home Health. During the assessment, R1 was noted to have a Stage 3 pressure injury on the left heel, with measurements of 2cm x 3cm x 0.2cm; and a Stage 2 pressure injury on right lateral malleolus, with measurement of 1cm x 1cm x 0.2cm. On 11/23/2021, three (3) facilities were contacted on behalf of R1 by their social worker and two (2) declined resident due to needs and services R1 required. However, Anita’s Care Villa accepted R1. Additionally, R1’s Admissions Agreement signed on 11/24/2022 states under Basic Services, facility will provide assistance with personal activities of daily living including dressing, eating, toileting, bathing, grooming, mobility tasks, and other personal care needs. According to R1’s medical records, R1 was scheduled for wound care for pressure injuries from 11/08/2021 to 01/06/2022 from DaranCare Home Health. Interviews conducted with facility staff and medical records review, confirmed that R1 was admitted to the facility with at least two (2) pressure injuries and both Staff and Administrator were aware of R1 having pressure injuries. Yet, R1 was still admitted to the facility. On 1/03/2022, R1 was reassessed again after 90 days and was noted to have new wounds. On 1/03/2021, R1 was noted to have an Unstageable pressure injury on the right lateral malleolus, with measurements of 3.5cm x 2.5cm x 0.5cm; a Stage 3 pressure injury on the right hip, with measurements of 0.75cm x 1.75cm x 0.2cm; and a Stage 3 pressure injury on the right buttock, with measurements of 1.5cm x 1.5cm x 0cm. Administrator stated that R1’s repositioning requirement every 2 hours by Home Health was a different level of care. Additionally, staff stated they were turning R1 every 2 hours while in bed, and the new pressure injuries were from R1 sitting on their wheelchair all day. However, facility did not have any records indicating how often they were repositioning R1. Moreover, Home Health nurse stated that new wounds are due to pressure from lying and not sitting.

...Continued on LIC 9099C...

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20220104110534
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: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411
VISIT DATE: 06/24/2022
NARRATIVE
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...Continued from LIC 9099C...

Furthermore, nurse notes revealed that nurse was continuously providing education to the caregivers on the importance of turning and repositioning R1 every 2 hours. Although R1 was receiving appropriate wound care from Home Health for the stage 3 and unstageable pressure injuries while at the facility by DaranCare Home Health, a stage 3 and unstageable pressure injuries are considered a Prohibited Health Condition. There were no records indicating that an exception request was submitted in order for R1 to be admitted or to remain at the facility. Based on the information and documentation obtained and reviewed, the allegations of “resident developed pressure injuries while in care” is deemed Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited.

Exit interview. Appeal Rights discussed. Copy of the report sent to the Administrator via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220104110534
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: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2022
Section Cited
CCR
87464(d)
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87464(d) Basic Services. A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457…This requirement is not met as evidenced by:
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The Administrator has agreed to submit a Statement of Understanding, explaining the steps the facility will follow to avoid similar issues from happening again and to ensure compliance to regulation regarding meeting basic care needs of the residents and submit to CCL by 7/01/2022.
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Based on the investigation, the licensee did not comply with the section cited above, as the facility did not ensure that R1’s care needs were met, which poses an immediate health and safety 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: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4