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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802420
Report Date: 08/02/2022
Date Signed: 08/02/2022 02:49:09 PM

Unsubstantiated


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
04/05/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220405135217
FACILITY NAME:PARK VISTA SENIOR LIVING 1-3FACILITY NUMBER:
565802420
ADMINISTRATOR:CHRISTOPHER ROMOFACILITY TYPE:
740
ADDRESS:370 ARCTURUS STREETTELEPHONE:
(805) 241-8000
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
08/02/2022
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Sherry NazariTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Facility is not providing resident proper care and supervision.
Resident sustained unexplained injuries while in care.
Staff incorrectly applied medicine on resident.
Facility did not properly manage resident's medications.
Facility is not maintained clean.
Facility lacked supplies.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Operations Director Sherry Nazari and explained the reason for the visit.

During the initial visit on 4/11/2022, the LPA conducted a physical plant tour at 10:25 a.m., audited and collected pertinent documents, reviewed medication records at 1:55 p.m., interviewed staff from 9:45 a.m. - 11:30 a.m., and interviewed residents at 11:50 a.m., and from 1:35 p.m. - 1:45 p.m. Additional interviews with current and former staff took place on 6/21/2022 at 12:07 p.m., and 3:24 p.m., an interview with a CVS Pharmacy representative took place on 6/21/2022 at 1:27 p.m., and interviews with family members of residents that resident in this facility took place on 6/21/2022 at 1:25 p.m. and 2:10 p.m.

Today, the LPA reviewed documents and conducted staff interviews at 12:35 p.m., and 1:30 p.m.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
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 6
Control Number 29-AS-20220405135217
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: PARK VISTA SENIOR LIVING 1-3
FACILITY NUMBER: 565802420
VISIT DATE: 08/02/2022
NARRATIVE
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Regarding the allegation: Facility is not providing resident proper care and supervision.
It was alleged that Resident #1 (R1) received the COVID-19 booster dosage without alerting R1’s responsible party nor without obtaining proper authorization. In addition, due to a COVID-19 outbreak, R1 was removed from the facility and quarantined outside of the facility. Lastly, it was mentioned that R1 experienced dehydration, which caused UTIs. Interviews and record review revealed that on approximately October 27, 2022, the facility had a COVID-19 booster clinic. Staff claimed that the clinic took place at Park Vista Senior Living 1-1 (565802418) and R1 requested to go with staff. Staff claimed that R1 went into the room where the vaccine dosages were administered but reiterated that R1 did not receive a dosage. R1’s responsible party indicated that upon seeing R1 on 10/30/2021, R1 had a Band-Aid on their left upper arm with a ‘red dot’ on the Band-Aid, which was presumed to be blood. Staff negated claims that R1 received the shot. An interview with the Pharmacy Manager from CVS Pharmacy revealed that pharmacy technicians are unable to administer a vaccine without authorization forms and confirmed that R1 did not have completed forms on file. It was further noted that facility staff would be in the room while the resident is receiving the dosage and said in order for a person to receive a dosage, staff would have handed them completed authorization forms. Whereas the Pharmacy Manager could not confirm or speculate as to why R1 had a Band-Aid on their arm, they reiterated that R1 did not receive a booster dosage as they did not have documentation to support the procedure, nor was a vaccine card for R1 updated. There were no photos or additional evidence to demonstrate that there was blood on the Band-Aid that was placed on R1’s left arm. Records review confirmed that the facility submitted an Incident Report documenting this occurrence on 11/05/2021.

Regarding the COVID-19 outbreak, interviews confirmed that the Administrator did not ask R1’s responsible party to remove R1 from the facility. R1’s responsible party made the decision to remove R1 from the facility to ensure R1’s safety. However, the other residents in the home continued to receive appropriate care. Interviews with responsible parties for residents whom reside in the facility denied claims that the residents received insufficient care and understood that individuals had to ‘shelter in place’ during the COVID-19 outbreak. Lastly, the LPA reviewed the Resident Progress Notes for R1 and the facility staff documented daily updates regarding R1’s progress. A review of daily notes revealed that staff documented times in which R1 consumed fluids, and also indicated the dates in which R1 would supplement meals with Ensures. Also, a review of the Medication Administration Record (MAR) documented when R1 received an Ensure, which the order read for the resident to receive an Ensure two times a day between meals.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220405135217
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: PARK VISTA SENIOR LIVING 1-3
FACILITY NUMBER: 565802420
VISIT DATE: 08/02/2022
NARRATIVE
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Based on the investigation, there is insufficient evidence to support the claim that the facility failed to provide proper care and supervision. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident sustained unexplained injuries while in care.


It was alleged that R1 had unexplained cuts and bruises on their skin. Photos revealed what appeared to be a bruise in R1’s ear, and a scratch on R1’s leg. Staff interviews revealed that at times, R1 would scratch themselves. Staff also believed that R1 experienced the cut on their leg due to a ‘blood blister’. Staff claimed that they also had this conversation with R1’s responsible party. The LPA reviewed the Resident Progress Notes, and the presence of the ‘leg scratch’ was documented on 2/25/2022. Regarding the bruise in the right ear, staff claim that it was due to R1’s hearing aid. It was further discussed that the bruise was brought to the attention of the staff once R1 returned to the facility after an extended stay with their family in early February 2022. Lastly, further review into the facility’s submitted incident reports indicated that on 04/03/2022, R1 lost their balance and fell, which resulted in R1 sustaining a red mark on the right side of their forehead.

Based on the investigation, there is insufficient evidence to support the claim that Resident #1 sustained unexplained bruises while in care. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff incorrectly applied medicine on resident.


It was alleged that staff incorrectly applied medicine on R1’s face, which caused R1 to have a bad reaction. Photos and interviews demonstrated that parts of R1’s face became red, blotchy, and flaky. A review of medication documents revealed on 10/13/2021, R1 was prescribed medication cream which was to be applied to affected areas twice daily for 3-6 weeks. According to the provided documentation regarding the medication, side effects include but are not limited to: erosion/redness, discomfort, recurrence, incomplete removal. In reviewing the documentation, even as directed, the applied medication has severe side effects which can impact the skin integrity. Further review from Mayo Clinic indicated that the above-mentioned side effects may ‘go away’ during treatment as the body adjusts to the medication. Additional side effects included dry, rough, or scaly skin, swelling or inflammation of the mouth, or raised/dark-red wart-like spots on the skin, especially when used on the face.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20220405135217
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: PARK VISTA SENIOR LIVING 1-3
FACILITY NUMBER: 565802420
VISIT DATE: 08/02/2022
NARRATIVE
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The LPA reviewed the facility's Resident Progress Notes, in which redness was noted on R1’s skin on 11/4/2021, but had begun ‘looking better’ on 11/13/2021. The LPA noted that on 11/05/2021, the facility submitted an Incident Report to the Department, reporting the occurrence of redness. The submitted report indicates that staff applied the cream on the ‘spotted area’, and there was no indication that it was applied all over R1’s face. Staff interviews negated claims that they incorrectly applied the cream to R1’s face, but also documented when R1 experienced a side effect of the medication. Staff also claimed that R1 had a tendency to touch their face at times, and were unsure if this aided in the spread of the cream.

Based on the investigation, there is insufficient evidence to support the claim that staff incorrectly applied medication to R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility did not properly manage resident's medications.


It was alleged that the facility failed to properly communicate with R1’s responsible party as it relates to R1’s medication refills. During the initial visit conducted on 4/11/2022, the LPA reviewed R1’s medications and found them to be in order and did not observe any medication errors. The LPA reviewed the facility Medication Administration Record (MAR) for February and March and did not observe any errors. Staff communicated that R1’s responsible party preferred to obtain R1’s medication refills. There were conflicting responses as it relates to whether R1’s responsible party was notified of a requested prescription refill in a timely manner. Staff noted that they would attempt to give R1’s responsible party sufficient notice to obtain the medications, but more importantly, staff denied that R1 ever missed a medication dosage. Based on the information obtained, there is insufficient evidence to support the claim that the facility did not properly manage R1’s medications. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility is not maintained clean.


It was alleged that the facility was dirty, and items were presumed to be dusty. During an initial visit conducted on 4/11/2022, the LPA conducted a physical plant tour of each resident room and common spaces and observed the facility to be clean. Resident personal items were observed, and they appeared to be well maintained and were not coated in dust at the time of the visit.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20220405135217
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: PARK VISTA SENIOR LIVING 1-3
FACILITY NUMBER: 565802420
VISIT DATE: 08/02/2022
NARRATIVE
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During today’s visit, the LPA conducted a physical plant tour of all resident rooms and common spaces. Areas observed included the common areas, dining room, kitchen, resident bedrooms, bathrooms, baseboards, countertops, and resident personal care items. During the 6/21/2022 visit and today, areas were observed to be appropriately cleaned and the LPA did not observe dirty or unsanitary areas.

Interviews confirmed that staff clean commonly touched surfaces every two hours. Interviews with staff, residents, and resident responsible parties supported claims that the facility appeared to be maintained clean and sanitary. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that the facility is dirty. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility lacked supplies.


It was alleged that during the time in which this facility had COVID+ residents isolating in the facility, the facility lacked cleaning supplies and Personal Protection Equipment (PPE). As a result, a family member had to bring in supplies. During the initial visit conducted on 4/11/2022 and the 6/21/2022 visit, the LPA observed the facility’s supply of Personal Protection Equipment (PPE) and cleaning supplies. The facility has a centralized location for supplies for all four facilities on the property. Staff negated claims that they have ever had to ask family members to bring in additional supplies and claimed that there were a sufficient amount of cleaning supplies and PPE for the home. Staff members indicated that families have brought in supplies on their own accord, and not at the request of a staff members. Out of the staff interviews conducted, only one staff mentioned going to out to purchase supplies as they did not grab supplies from the centralized location on the property. Interviews with family members did not reveal evidence to support claims that they have been asked to bring in supplies due to the insufficient amount observed at the facility.

Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that the facility lacked supplies. This allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6