565802420-8-3-2022-29-AS-JAPL-CH828H-20220811171022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802420
Report Date: 08/03/2022
Date Signed: 08/03/2022 10:36:52 AM

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
04/05/2022 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20220405135217

FACILITY NAME:	PARK VISTA SENIOR LIVING 1-3		FACILITY NUMBER:	565802420
ADMINISTRATOR:	CHRISTOPHER ROMO		FACILITY TYPE:	740
ADDRESS:	370 ARCTURUS STREET		TELEPHONE:	(805) 241-8000
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	08/03/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sherry Nazari		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Facility did not properly manage resident's personal belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit to deliver the findings for the above allegations. 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. and on 8/3/2022 at 5:13 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. On 8/2/2022, the LPA reviewed documents and conducted staff interviews at 12:35 p.m., and 1:30 p.m.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

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: 08/03/2022

NARRATIVE

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Regarding the allegation: Facility did not properly manage resident's personal belongings.
It was alleged that the resident’s personal belongings went missing, such as personal clothing items. There were conflicting staff statements regarding the laundering of R1’s clothing. Some staff claimed they would wash the resident clothing separately and did their best not to mix clothing items. However, staff admitted that R1’s clothing could have been laundered with other resident belongings and could have been the source as to why they were missing. Staff admitted that it was brought to their attention that R1’s undergarments had gone missing by R1’s responsible party, yet staff were unable to share if the items were recovered. Staff admitted that R1 initially wore undergarments when they were initially admitted to the facility, and said R1 soon transitioned to wearing briefs. Another item that oftentimes went missing were R1’s hearing aids. Staff alleged that R1 would oftentimes remove the hearing aids out of their ear and would accidentally place them around the house, or unknowingly in the trash can. The LPA reviewed the Resident Progress Notes, and the facility would oftentimes document when R1’s hearing aids would go missing and their efforts in communicating the instances to the appropriate parties and efforts in locating the missing items.

Based on the investigation, there is sufficient evidence to support the claim that the facility did not properly manage the resident’s personal belonging. Staff admitted that they had been informed of R1’s items going missing and were unable to communicate whether the items were retrieved. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/12/2022 Section Cited CCR 87468.2(a)(25)	1 2 3 4 5 6 7	87468.2(a)(25) Additional Personal Rights of Residents in Privately Operated Facilities. Residents … shall have all of the following personal rights: To protection of their property from theft or loss … The following is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to the following: 1. Review the Theft and Loss policy with all staff. Have staff sign off once reviewed. Submit sign-in sheet to CCL by 8/12/2022. 2. Submit Plan of Action, detailing the facility’s process to ensure that resident items are properly safeguarded. Submit by 8/12/2022
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above, as R1’s items were lost and were not misplaced or located, which poses a potential personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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 1-3		FACILITY NUMBER:	565802420
ADMINISTRATOR:	CHRISTOPHER ROMO		FACILITY TYPE:	740
ADDRESS:	370 ARCTURUS STREET		TELEPHONE:	(805) 241-8000
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	08/03/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sherry Nazari		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Facility did not have sufficient staff to meet the residents' needs.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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: 08/03/2022

NARRATIVE

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Regarding the allegation: Facility did not have sufficient staff to meet the residents' needs.
It was alleged that the facility did not have sufficient staff to meet the residents’ needs during a time period where the facility had COVID-19 cases. Interviews revealed that during the time period where there were active COVID-19 cases in the community (approximately 1/24/2022 – 2/11/2022), the licensee ensured that this facility had two staff working on each shift. Interviews conducted with current and former staff whom worked at the facility during the COVID outbreak revealed that the majority of the staff confirmed that they were sufficiently staffed during that time, and communicated that they did not work alone during their assigned shift. There were conflicting statements for staff whom worked the evening shift; whereas one staff claimed that they had worked alone, the other staff assigned to the evening shift negated claims and noted that they had always worked in pairs. Interviews with family members of residents whom resided in the facility at that time denied claims that the facility was understaffed and felt that staff were able to meet resident care needs during that time.

Based on the investigation, there is insufficient evidence to support the claim that the facility did not have sufficient staff to meet the residents' needs. 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.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 5