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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802418
Report Date: 08/03/2022
Date Signed: 08/03/2022 10:41:49 AM


Document Has Been Signed on 08/03/2022 10:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PARK VISTA SENIOR LIVING 1-1FACILITY NUMBER:
565802418
ADMINISTRATOR:SHAHRZAD NAZARIFACILITY TYPE:
740
ADDRESS:350 ARCTURUS STREETTELEPHONE:
(805) 492-8888
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
08/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sherry NazariTIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted a Case Management – deficiency inspection due to a deficiency observed during the investigation of complaint, control # 31-AS-20191219100413, which was investigated by LPA Mita Amin. The LPA met with Sherry Nazari and explained the reason for the visit.

During the investigation of the complaint allegations, it was revealed that Resident#1 (R1) was hospitalized on 12/22/19 for a syncope episode. On 3/05/20 at 10 am, the LPA reviewed the hospital records, which indicated that R1 had multiple pressure injuries from stage I to II at the time of admission.

The information obtained during a staff interview on 12/26/19 at about 10 am and on 1/22/20 about at 11 am, revealed that R1 was aggressive, combative and was refusing the services which were to be provided by facility staff. The investigation also revealed that facility staff were aware of R1’s health and medical condition; and, that R1 was susceptible to pressure injuries and/or skin integrity issues.

Medication technicians and administrators were aware of the challenges they were experiencing in attempting to provide care to R1. Staff were concerned about the violation of R1’s personal right as R1 could refuse the services; and, as a result, the facility staff were frequently unable to provide the essential daily care (changing soiled diapers) for the R1, due to R1’s refusal to cooperate with the staff. As a result of R1 refusing services, R1 developed pressure injuries.

When staff continued to attempt to assist R1; and, R1 continued to refuse their help, it was the licensee and/or administrator’s responsibility to notify R1’s physician and R1’s responsible person(s) to inform them that facility staff were unable to meet R1’s needs; and, that they had concerns that skin breakdown might develop. If that had occurred, other alternatives may have been provided to assist in redirecting R1 from their aggressive and combative behavior.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARK VISTA SENIOR LIVING 1-1
FACILITY NUMBER: 565802418
VISIT DATE: 08/03/2022
NARRATIVE
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It is ultimately the licensees’ responsibility to reassess the resident to ensure that they can meet the resident’s needs. Therefore, a deficiency shall be issued as the Administrator was aware of R1’s behavior and refusal of services; however, failed to seek the appropriate assistance.

Pursuant to Title 22, California Code of Regulation, the following deficiency will be cited (refer to LIC 809-D).
Exit interview conducted. Appeal rights provided. A copy of this report was emailed for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/03/2022 10:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: PARK VISTA SENIOR LIVING 1-1
FACILITY NUMBER: 565802418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
Section Cited

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87466 Observation of the Resident. Licensee shall ensure ... assistance is provided when ... observation reveals unmet needs ... Licensee shall ensure ... changes are ... brought to the attention of the ... physician and ... responsible person...
This requirement is not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above to ensure that R1’s physician and responsible party were notified of R1s refusal for care, as R1 sustained pressure injuries due to the refusal of care, 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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