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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850067
Report Date: 06/07/2023
Date Signed: 06/15/2023 08:35:10 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
08/25/2022 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20220825171602
FACILITY NAME:VISTA AT SIMI VALLEYFACILITY NUMBER:
565850067
ADMINISTRATOR:CAROL ANN LEROSEFACILITY TYPE:
740
ADDRESS:1236 ERRINGER ROADTELEPHONE:
(805) 351-8802
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:130CENSUS: 82DATE:
06/07/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brimen VivarTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility did not bathe resident.
Facility is not responding timely to resident's pendant calls for help
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings regarding the above noted allegations. LPA initially met with executive director Maddi Lewis and explained the reason for the visit. At 11:00 a.m. LPA met with administrator Brimen Vivar and discussed complaint findings.

On 9/1/2022, LPA had conducted interviews with staff starting at 1:39 p.m., interviewed resident 1 (R1) at 2:55 p.m. and reviewed records at 2:20 p.m. On 5/12/2023, LPA interviewed staff at 1:00 p.m. and reviewed records at 2:00 p.m. LPA had requested pendant response records for August 2022 but the administrator was not able to retrieve them, even with the help of the company they use to store the information. In addition, records for R1 regarding bathing could not be found. R1 is no longer at the facility. Therefore, findings are based on interviews with R1 and staff.

(continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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 5
Control Number 29-AS-20220825171602
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: VISTA AT SIMI VALLEY
FACILITY NUMBER: 565850067
VISIT DATE: 06/07/2023
NARRATIVE
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(continued from 9099)

Regarding the allegation: Facility did not bathe resident.
During an interview with R1, they stated they were supposed to be bathed three times per week in the evening. However, R1 stated sometimes they only receive one or two showers per week. Staff indicated R1 was supposed to be bathed three times per week in the evening and if R1 did not get bathed the morning shift would receive complaints from R1. R1's Needs and Services Plan dated 4/28/2022, indicates R1's bathing schedule was Monday, Wednesday and Friday during the evening shift. LPA had requested documentation from the administrator regarding R1's bathing as LPA was aware the previous facility administrator had staff start logging when residents were bathed or if they refused to be bathed. Since R1 is no longer at the facility R1's file was closed. The administrator was unable to retrieve the bathing logs which were noted in end of shift reports for all residents. The current administrator closely monitors the end of shift reports to watch for concerning incidents and to ensure needs are met. Therefore, the allegation the facility did not bathe resident is deemed substantiated at this time.

Regarding the allegation: Facility is not responding timely to resident's pendant calls for help.
During an interview with R1, they stated sometimes it can take staff up to an hour to respond to their pendant call. R1 stated usually it was approximately 20 minutes for staff to respond but sometimes staff would arrive right away. R1 thought that was due to staff location in the facility when they used their pendant. LPA interviewed staff who stated R1 had complained on several occasions about pendant call response times. LPA was not able to review pendant call response times as the administrator was not able to obtain the response logs for August 2022. Therefore, findings are based on interviews with R1 and staff. The allegation facility is not responding timely to resident's pendant calls for help is deemed substantiated at this time. The administrator indicated they have improved on response times since 2022 as they have conducted pendant response time training with all staff. LPA reviewed current pendant response times which appear to run between one to five minutes with a couple outliers at ten to fifteen minutes but those are still within the facility expectations for call response times.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).
Exit interview conducted. A copy of the report and appeal rights were provided to the administrator.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 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
08/25/2022 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20220825171602

FACILITY NAME:VISTA AT SIMI VALLEYFACILITY NUMBER:
565850067
ADMINISTRATOR:CAROL ANN LEROSEFACILITY TYPE:
740
ADDRESS:1236 ERRINGER ROADTELEPHONE:
(805) 351-8802
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:130CENSUS: 82DATE:
06/07/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brimen VivarTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility changed resident's medication without obtaining permission.
Facility did not assist with the self-administration of the resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings regarding the above noted allegations. LPA initially met with executive director Maddi Lewis and explained the reason for the visit. At 11:00 a.m. LPA met with administrator Brimen Vivar and discussed complaint findings.

On 9/1/2022, LPA had conducted interviews with staff starting at 1:39 p.m., interviewed resident 1 (R1) at 2:55 p.m. and reviewed records at 2:20 p.m. On 5/12/2023, LPA interviewed staff at 1:00 p.m. and reviewed records at 2:00 p.m.

(continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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 5
Control Number 29-AS-20220825171602
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: VISTA AT SIMI VALLEY
FACILITY NUMBER: 565850067
VISIT DATE: 06/07/2023
NARRATIVE
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(continued from 9099-A)

Regarding the allegation facility changed resident's medication without obtaining permission:
LPA reviewed medication records. All medications were prescribed by R1's physician. R1 stated they thought their injectable medication was changed by facility staff. Facility staff stated R1's physician prescribed all medications and their pharmacy sent the medications to the facility. The appearance of the injectable medication had changed but it was the same medication. Based on records reviewed and interviews the allegation facility changed resident's medication without obtaining permission is deemed Unsubstantiated at this time.

Regarding the allegation facility did not assist with the self-administration of the resident's medication:
LPA reviewed medication records, interviewed staff and interviewed R1. There was concern which was addressed with R1 by the prior administrator and health services director. R1's hands were very shaky and they were concerned R1 would no longer be able to inject their injectable medication. R1 stated the prior health services director and the medication technicians helped with their injectable medication by performing hand over hand assistance. LPA confirmed with the lead medication technician that they performed hand over hand assistance with R1's injectable medications. R1 did not go without any of their medications. Therefore, based on record review and interviews, the allegation facility did not assist with the self-administration of resident's medication is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report and appeal rights were provided to the administrator.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220825171602
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: VISTA AT SIMI VALLEY
FACILITY NUMBER: 565850067
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2023
Section Cited
CCR
87468(a)(4)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4)To care, supervision, and services that meet
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Administrator stated she conducts monthly training regading pendant responses. The last training was conducted on 5/25/2023. LPA obtained evidence of training.
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their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement was not met as evidenced by: Based on interviews, response times to calls for assistance have taken over 20 minutes to an hour in some
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instances, which poses a potential health, safety or personal rights risk to persons in care.
Type B
06/14/2023
Section Cited
CCR
87464(f)(4)
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Basic Services. Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal … such as dressing, eating, bathing… This requirement is not met as evidenced by:
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The Administrator has agreed to the following: conduct training for staff regarding bathing. Administrator will send evidence of training by 6/14/2023.
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Based on interviews, R1 did not receive three showers a week as indicated in their needs and services plan. This poses a potential health and safety risk to residents in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5