565802418-6-24-2020-31-AS-JAPL-BUSSLS-20201027135848

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802418
Report Date: 06/24/2020
Date Signed: 06/24/2020 03:02:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2020 and conducted by Evaluator Mita Amin

COMPLAINT CONTROL NUMBER: 31-AS-20200417161354

FACILITY NAME:	PARK VISTA SENIOR LIVING 1-1		FACILITY NUMBER:	565802418
ADMINISTRATOR:	SHAHRZAD NAZARI		FACILITY TYPE:	740
ADDRESS:	350 ARCTURUS STREET		TELEPHONE:	(805) 492-8888
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	06/24/2020
		UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	Nazari Shahrzad/ administrator		TIME COMPLETED:	01:29 PM

ALLEGATION(S):

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Inappropriate conduct by staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mita Amin conducted tele-visit for a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Nazari Shahrzad the facility administrator.

It is alleged that staff#1(S1) was observed lying in bed with resident#1(R1), rubbing head and the door to R1's room was closed.

Investigation include interviews with administrator Chris Romo on 4/22/20 at 11:10 am and Sherry Nazari on 4/23/20 at 8:30 am. On 4/27/20 at 9am, LPA reviewed the Ventura County Police report regarding their visit to the facility on 3/31/20 to investigate the above incident. LPA reviewed the facility records on 4/27/20 at 11 am including R1's physician report, Need and service plan, staff members statement and staff's facility files. On 4/23/20 at 2:19 pm LPA interviewed S2 via phone.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Mita Amin	TELEPHONE: (818) 241-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2020

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 31-AS-20200417161354

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME: PARK VISTA SENIOR LIVING 1-1	FACILITY NUMBER: 565802418
	VISIT DATE: 06/24/2020

NARRATIVE

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The interviews with the administrators revealed that due to the diagnosis of dementia, R1 sometimes gets agitated and rubbing the head helps R1 calm down. Review of the other staff members statements also collaborate the information about the agitation and need of physical assurance. Based on the administrator's interview with S1 and written statement provided by S1, she was not in the bed with R1, but was sitting on the side of bed, gently rubbing R1's head to comfort R1. S1 did admit her mistake of closing the door behind her. The administrator, Sherry stated S1 is long time employee of the facility, does not have any negative comment or complaint from anyone and they have not observed any inappropriate behavior towards residents.

Based on the Officer's interview with S1, she was sitting on side of bed and rubbing R1's forehead, was not in the bed with R1. There is no other witness to this incident. Officer was unable to interview R1 due to cognitive limitations. Police record revealed that due to the conflicting statement of staff#1(S1) and staff#2 (S2), they were unable to establish the crime.

LPA was unable to interview R1 due to diagnosis of dementia.

Based on the information obtained during this investigation there is an insufficient evidence to support the allegation that “Inappropriate conduct by staff“ therefore, the above allegation is deemed unsubstantiated, that means that allegation may or may not be true but there is no evidence present at this time. No deficiency issued.

A telephonic exit interview was conducted with Ms. Shahrzad, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Mita Amin	TELEPHONE: (818) 241-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2020

LIC9099 (FAS) - (06/04)

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