565802454-4-14-2023-29-AS-DPEA-CR928V-20230425171057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802454
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:19:22 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
11/29/2022 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20221129161157

FACILITY NAME:	FOOTHILLS AT SIMI VALLEY, THE		FACILITY NUMBER:	565802454
ADMINISTRATOR:	BOGOYEVAC, LEATRICE		FACILITY TYPE:	740
ADDRESS:	5300 E LOS ANGELES AVENUE		TELEPHONE:	(805) 583-3500
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	175	CENSUS: 56	DATE:	04/14/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Lea Bogoyevac, Administrator & Vanathda Dunn, Memory Care Director		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Administrator Lea Bogoyevac, and Memory Care Director Vanathda Dunn and explained the reason for the visit.
On 11/29/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Care. It was alleged that facility staff neglected Resident #1 (R1) resulting in stage 3 pressure injuries to feet, buttocks, and testicles. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Dennis Seng.
On 11/30/2022, between 1:15pm and 3:10pm, Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced initial complaint visit. LPA Smith met with staff Elizabeth Chavez and Lea Bogoyevac and explained the reason for the visit. During the visit, the LPA collected documents and interviewed staff at 1:48pm. Investigator Seng conducted interviews on 02/15/2023 with R1’s resident representative, attempted to interview R1 who was unable to be interviewed due to deteriorating health and on hospice, with the Administrator, Director of Health Management, staff, residents, and Home Health LVN. (Continue)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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-20221129161157

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: FOOTHILLS AT SIMI VALLEY, THE	FACILITY NUMBER: 565802454
	VISIT DATE: 04/14/2023

NARRATIVE

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In addition, the investigator reviewed Adventist Health medical records, home health notes, and facility file documents related to R1.

R1’s Physician Report, dated 10/03/2022, noted R1 was primarily diagnosed with chronic obstructive pulmonary disease. R1 was non-ambulatory and bed bound. R1 required maximum assistance with Activities of Daily Living (ADLs) and was unable to transfer on own from bed. R1 required assistance with medication, ADLs, feeding, ambulation, and supervision. R1 was able to communicate needs, but was not able to bathe, dress/groom self, and not able to care for own toileting needs.

The investigation revealed R1 was admitted to the facility from a skilled nursing facility (SNF) on 10/16/2022. Upon admittance to the facility, R1 was being treated regularly by Active Plus Home Health for stage II pressure injuries to buttocks, sacrum and testicles. Information obtained through interviews revealed that the facility staff repositioned and checked on R1 every 2 hours. Staff were not trained by home health to change R1’s bandages. Staff were instructed to contact the facility Med Tech who then contacted the home health if the bandages became soiled or wet, and the home health nurse would then cleanse the pressure injury and change the bandage. The staff were not able to observe the pressure injuries or if they worsened as they were covered with bandages.

The home health progress notes revealed that R1 received a visit from home health on 11/17/2022 and was diagnosed with a stage two injury only to the Sacrococcyx region measuring 2.5cm x 2cm during the visit. Home health staff changed the bandages and cleaned the pressure injury during the visit. From 11/17/2022 to 11/19/2022 facility staff did not witness any need to change R1’s bandages. On 11/19/2022, R1 complained of abdominal pain and was taken to the hospital. While at the hospital, R1 was given a pressure injury assessment on 11/21/2022 and was diagnosed with a stage three pressure injury on feet, buttocks and testicles. R1 was treated and released back to the facility under hospice care on 11/23/2022.

Based on document review and interviews conducted during the course of the investigation, there was insufficient evidence to substantiate the allegation of Neglect/Lack of Care and Supervision leading to a stage three pressure injury to R1 who was hospitalized on 11/19/2022 due to abdominal pain. Therefore, the Department has determined that the allegation “Neglect/Lack of Care and Supervision - Resident sustained pressure injuries while in care” is unsubstantiated at this time.
Exit interview conducted, a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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