565802441-9-6-2022-29-AS-DPEA-CJNVWC-20220927164742

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802441
Report Date: 09/06/2022
Date Signed: 09/06/2022 12:31:30 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
08/16/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20220816111702

FACILITY NAME:	LOVELY COMMUNITY HEALTHCARE		FACILITY NUMBER:	565802441
ADMINISTRATOR:	TOUME, CILVA		FACILITY TYPE:	740
ADDRESS:	52 W NORMAN AVENUE		TELEPHONE:	(805) 852-8770
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	09/06/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cilva Toume		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility food caused resident to become ill.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. On 8/18/2022, LPA Arroyo conducted an initial 10-day complaint inspection. On today’s visit, LPA Arroyo met with Administrator Cilva Toume. Entrance interview conducted.

During the initial visit on 08/18/2022, LPA Arroyo conducted a physical plant tour, interviewed the administrator, one staff, and four residents at 1:16pm. At 2:35pm, the LPA conducted a resident file review and obtained copies of resident records and other pertinent documents. On 08/24/2022, LPA Arroyo conducted a telephonic interview with resident’s family member at 11:57am.

(...Report Continued on LIC 9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

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-20220816111702

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: LOVELY COMMUNITY HEALTHCARE	FACILITY NUMBER: 565802441
	VISIT DATE: 09/06/2022

NARRATIVE

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(Report Continued from LIC 9099...)

It was alleged that facility food caused resident to become ill. It was reported that Resident #1 (R1) was given a yogurt to eat and after consuming, R1 began vomiting violently for approximately 45 minutes before calling 9-1-1 and being transported to the hospital. Information gathered revealed that R1 was transported and admitted to the hospital on 7/29/2022 due to nausea, vomiting, and hypokalemia. Additionally, R1 was advised to eat high potassium food as documents obtained and reviewed revealed R1 had low potassium levels. Interviews conducted revealed R1 has been ordering outside food to be delivered to the facility. Also, R1 has been refusing to eat the facility’s food for at least two months. Additionally, R1 has mainly been consuming protein bars and water as their daily meals. Furthermore, R1 reported taking Zofran daily to not get nauseas and has not been taking that medication for a few months. Centrally stored medication log for R1confirmed R1 has not been taking medication Zofran since April 2022. Interviews with residents revealed the facility provides three meals a day plus snacks in between. Correspondingly, residents displayed no concerns and stated they felt safe living at the facility. Based on the information gathered and interviews conducted, there is insufficient evidence to support the allegation, “facility food caused resident to become ill”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of the report will be emailed to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC9099 (FAS) - (06/04)

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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
08/16/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20220816111702

FACILITY NAME:	LOVELY COMMUNITY HEALTHCARE		FACILITY NUMBER:	565802441
ADMINISTRATOR:	TOUME, CILVA		FACILITY TYPE:	740
ADDRESS:	52 W NORMAN AVENUE		TELEPHONE:	(805) 852-8770
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	09/06/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cilva Toume		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility not providing care to resident.
Facility illegally evicted resident.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20220816111702

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: LOVELY COMMUNITY HEALTHCARE	FACILITY NUMBER: 565802441
	VISIT DATE: 09/06/2022

NARRATIVE

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(Report Continued from LIC 9099...)

It was alleged that facility is not providing care to resident. It was reported that staff are not responsive to R1’s care needs and R1’s family has come to the facility to provide care in the absence of a caregiver. Information gathered revealed R1 was admitted to the facility on 8/17/2017. Additionally, R1’s Admissions Agreement dated 8/17/2017, states on page 2, “assistance with personal activities of daily living as follows: dressing, eating, bathing, grooming, other personal care needs: ice packs PRN, stack toilet paper, occasional help with electronics, and set up weights for physical therapy exercises”. These are all basic services the facility had agreed to provide to R1 upon admission. Interviews conducted revealed R1 has become agitated and aggressive towards facility staff. Furthermore, there have been two staff that were working with R1 and both have quit in the last 30 days. However, due to the lack of staff, R1’s family has been coming to the facility from 7pm to 10pm to assist R1 with their personal activities of daily living as the facility does not have a caregiver to care for R1. Therefore, based on interviews and records obtained and reviewed, the allegation of “facility is not providing care to resident.” is deemed Substantiated at this time.

It was further alleged that facility illegally evicted resident. It was reported that resident received a 30-day “notice to vacate the room” from the Administrator. Additionally, eviction letter notes R1’s family member is listed as the responsible party; however, R1 claims to be self-responsible. Review of documents revealed R1 was given an eviction letter dated 8/03/2022. In the eviction notice, the Administrator stated that R1’s health condition requires immediate transfer to protect the health and safety of all residents and staff in the facility. However, the Administrator did not identify such specific behaviors in the eviction notice, and no incident reports were provided to the department. As required by Title 22 Regulations, Section 87224 and §1569.683 the facility failed to provide the following: Specific facts to permit determination of the date, place, witnesses, and circumstances concerning the reasons noted. Information about resources available to assist the resident in identifying alternative housing and care options, including public and private referral services and case management organizations. Information about the resident’s right to file a complaint with the CDSS regarding the eviction, with the name, address, and telephone number of the nearest office of community care licensing and the State Ombudsman.

(Report Continued on LIC 9099C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220816111702

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: LOVELY COMMUNITY HEALTHCARE	FACILITY NUMBER: 565802441
	VISIT DATE: 09/06/2022

NARRATIVE

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(Report Continued from LIC 9099C...)

A statement that if a licensee pursues an unlawful detainer action, the resident must be served with a summons and complaint. A statement that the resident has the right to contest the eviction in writing and through a hearing. Based on the 30-day notice lacking the required information as stated above, the 30-day eviction letter is not valid. Therefore, the allegation of “facility illegally evicted resident” is deemed as Substantiated.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D).

Exit interview conducted. Citation issued. Appeal Rights discussed. A copy of report provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20220816111702

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: LOVELY COMMUNITY HEALTHCARE	FACILITY NUMBER: 565802441
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/16/2022 Section Cited CCR 87464(c)	1 2 3 4 5 6 7	87464(c)The admission agreement shall specify which of the basic services are desired and/or needed by, and will be provided for, each resident. The requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee has agreed to review and submit a statement of understanding on Regulation 87464 Basic Needs to CCL no later than 9/16/2022.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as the facility is not providing the basic needs care outlined per the Admissions Agreement signed and dated on 8/17/2017, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 09/16/2022 Section Cited CCR 87224(d)(B)(1)(2)	1 2 3 4 5 6 7	87224(d)(B)(1)(2) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts...ferral services that will aid in finding alternative housing. Case management organizations which help manage individual care and service needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to read, review, and submit a statement of understanding on Regulation 87224 Eviction Procedures to CCL no later than 9/16/2022.
	8 9 10 11 12 13 14	Based on record review, the licensee did not comply with the section cited above as the eviction notice did not include referral services and a notice of case management organization which help manage individual care and service needs, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC9099 (FAS) - (06/04)

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