565802421-3-9-2023-29-AS-JAPL-CQ8SWZ-20230324141508

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802421
Report Date: 03/08/2023
Date Signed: 03/09/2023 08:27:24 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
10/08/2021 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20211008094526

FACILITY NAME:	PARK VISTA SENIOR LIVING 1-4		FACILITY NUMBER:	565802421
ADMINISTRATOR:	CHRISTOPHER ROMO		FACILITY TYPE:	740
ADDRESS:	380 ARCTURUS STREET		TELEPHONE:	(805) 492-2000
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	03:53 PM
MET WITH:	Sherry Nazari		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Resident sustained bruising while in care
Resident sustained a fall while in care
Staff did not report an unusual incident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara arrived unannounced for a subsequent complaint visit to deliver the findings for the above allegations. The LPA met with Operations Director Sherry Nazari at 4:10 p.m. and explained the reason for the visit.

During the initial visit on 10/14/2021, the LPA conducted a physical plant tour at 9:10 a.m., reviewed records at 10:25 a.m., interviewed staff at 9:18 a.m. and interviewed residents at 9:35 a.m. During today's visit LPA met with staff at 3:53 p.m. and toured the faciltiy at 3:55 p.m.

(continued on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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 29-AS-20211008094526

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 1-4	FACILITY NUMBER: 565802421
	VISIT DATE: 03/08/2023

NARRATIVE

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Regarding the allegations R1 sustained bruising while in care and R1 sustained a fall while in care: A record review showed R1 sustained several falls while at the facility and sustained bruising due to each fall. Incident reports filed with CCL were dated 2/24/21, 3/1/21, 3/5/21, and 12/11/21. Each incident report indicated R1's responsible party was notified of each fall. Staff stated there was a motion sensor in R1's room and on the incident report dated 3/5/21 it indicated staff were instructed to watch R1 more closely due to being a fall risk. However, there was no indication on the incident reports that R1's physician was notified of these falls.

On 3/8/23 at 4:25 p.m. Operations Director showed LPA her phone texts to a nurse practitioner at R1's physician's office starting 12/11/21 and a video conference on 10/12/21 at 1:22 p.m. with the nurse practitioner. The Operations Director stated she contacted the physician's office for the other incidents but did not note that on the incident reports nor did she have evidence of contacting the physician's office for the prior falls R1 had at the facility. Staff and documents confirmed R1 had multiple falls which resulted in bruising, therefore these allegations are deemed substantiated at this time.

Regarding the allegation Staff did not report an unusual incident: During staff interviews it was confirmed R1 fell on or about 10/03/21 during the night and sustained bruising. The daytime staff stated they were aware of the incident because R1 had gone to the hospital but the nighttime staff did not write anything down in their notes about it. Although staff was aware of the incident, it was never reported to CCL. Therefore, 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. 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: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211008094526

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 1-4	FACILITY NUMBER: 565802421
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/15/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging for medical and dental care	1 2 3 4 5 6 7	Licensee will review requirements of this section and provide a written statement outlining their understanding of the requirements to CCL by 3/15/23.
	8 9 10 11 12 13 14	appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on records reviewed and interviews, the licensee did not comply with the section cited above, as there was no evidence R1’s physician was consulted with or notified of	8 9 10 11 12 13 14	R1's falls on 2/24/21, 3/1/21, and 3/5/21, which poses a potential health and safety risk to residents in care.
Type B 03/15/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events	1 2 3 4 5 6 7	Licensee will review reporting requirements with all faciltiy staff, submit evidence of staff training and provide a written statement of understanding regarding reporting requirements to CCL by 3/15/23
	8 9 10 11 12 13 14	specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident...	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on records reviewed and staff interviews, R1 fell on 10/03/21 and sustained bruising but the facility never filed an incident report with CCL, which poses a potential health and safety risk to residents in care.

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: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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