565802461-1-20-2023-29-AS-JAPL-CNLRE4-20230131115654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802461
Report Date: 01/20/2023
Date Signed: 01/20/2023 04:25:49 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
01/12/2023 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230112091535

FACILITY NAME:	SUNRISE AT WOOD RANCH		FACILITY NUMBER:	565802461
ADMINISTRATOR:	EDITH KENNEDY		FACILITY TYPE:	740
ADDRESS:	190 TIERRA REJADA RD		TELEPHONE:	(805) 584-8881
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	100	CENSUS: 65	DATE:	01/20/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Edith Kennedy		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.
Facility staff did not provide a safe environment for resident while in care.
Facility staff did not provide resident timely medical attention.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegations. LPA met with Executive Director/Administrator Edith Kennedy and explained the reason for the visit.

At 9:35 a.m. LPA met with Administrator. At 9:55 a.m. LPA conducted a brief tour of Resident 1's (R1) room. Starting at 10:02 a.m. LPA started interviewing staff. At 12:52 p.m. LPA obtained pertinent documents.

Regarding the allegation facility staff did not provide a safe environment for resident while in care, the complaint indicated R1's bed and lamp would be unplugged from the outlet in R1's room. The complainant presumed there was an electrical problem. LPA observed R1 does not have a bed. R1's responsible party told facility staff upon moving in R1 does not like to sleep in a bed due to mobility issues and prefers to sleep in a recliner. LPA observed the recliner, lamp, digital frame and other items were all plugged into an electric strip

(continued on 9099-C)

Unsubstantiated

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: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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 3

Control Number 29-AS-20230112091535

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: SUNRISE AT WOOD RANCH	FACILITY NUMBER: 565802461
	VISIT DATE: 01/20/2023

NARRATIVE

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behind the recliner. All staff interviewed denied ever unplugging these items and all indicated R1 never had a bed while at this facility. R1 does have a "hospital bed" at the skilled nursing facility (SNF) where R1 is temporarily staying. It is possible the complaint about a bed being unplugged may have been against the SNF and not this facility. Based on interviews and observations, this allegation is deemed Unsubstantiated at this time.

Regarding the allegation facility staff did not provide resident timely medical attention, LPA reviewed records and interviewed staff. Records show that on 11/18/22 staff observed a hematoma on R1's lower right leg with blood weeping out of the bottom. One of the wellness nurses at the facility treated and wrapped the leg. At approximately 9:00 p.m. on 11/18/22, staff observed more blood weeping out of the hematoma and called 9-1-1 so R1 could be taken to the hospital. R1 was released on 11/19/22 back to the facility with orders to temporarily start and stop some medications and start home health wound care, including a visit from a wound specialist. Facility wellness nurses ensured the wound was taken care of until home health started wound care. On 11/21/22, home health started coming to the facility to provide wound care to R1's right leg. Staff continued to monitor the area. On 11/28/22, the wound care specialist visited the facility and the wound was at Stage 2. The wound care specialist treated and wrapped the wound. Staff continued to monitor the wound between home health visits and continued to apply a compression wrap on R1's left leg as ordered by R1's physician. On 12/3/22, one of the facility wellness nurses observed the wound had black discoloration, weeping from wound and R1's leg was painful. The nurse reported this to R1's physician and R1 was taken by ambulance (9-1-1) to the hospital. R1 was admitted to the hospital and then later sent to a SNF for rehabilitation and wound care. Based on interviews and record review, the facility immediately acted on discovery of R1's right leg hematoma by treating the wound and when it worsened that same day they sent R1 to the hospital. R1's wound care was then performed by home health and monitored by facility staff, when the wound worsened again facility staff sent R1 back to the hospital, therefore this allegation is deemed Unsubstantiated at this time.

(continued 9099-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230112091535

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: SUNRISE AT WOOD RANCH	FACILITY NUMBER: 565802461
	VISIT DATE: 01/20/2023

NARRATIVE

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Regarding the allegation the resident sustained an unexplained injury while in care, LPA interviewed staff and reviewed records. In the past year, R1 has suffered four skin tears. R1 was unable to say how the skin tears occurred. Staff who were interviewed stated they believed R1 may get skin tears by bumping into the sides of R1's walker. Staff 1 (S1) stated R1 was able to ambulate using a walker; R1 walks very slowly and carefully and staff monitor R1 while ambulating to prevent R1 from bumping into things. Staff believe when R1 accidentally bumps the walker into something it may hit R1's leg. Staff have never witnessed a skin tear occur but assume it is due to R1 bumping into the walker. In addition, S1 has witnessed R1 attempting to remove the physician ordered leg compression wraps. The act of tearing off the wrap may also cause skin tears. It was noted by all staff that R1 has very delicate "thin" skin on R1's arms and legs. R1 also takes a blood thinner which causes bumps to bruise more easily and scratches/tears to bleed. Staff stated R1 sometimes transfers on their own from their recliner to their walker, however usually R1 will request staff assistance with transfers. Staff stated R1 uses their walker to ambulate around the common areas adjacent to R1's room, otherwise R1 uses a wheelchair to go further distances. Based on interviews and record review, it appears staff make every attempt to assist R1 with transfers, ensure R1 is safely ambulating, follow physician orders for leg compression wraps, and encourage R1 to leave the wraps in place. While nobody has witnessed how R1's is sustaining skin tears, it is presumed based on staff observations that R1 was sustaining skin tears by either bumping into their walker or scratching their legs and arms by trying to remove pressure wraps, therefore this allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

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