565850067-2-21-2024-29-AS-DPEA-D2WV58-20240229150732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850067
Report Date: 02/21/2024
Date Signed: 02/21/2024 05:04:07 PM

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
04/11/2023 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20230411162428

FACILITY NAME:	VISTA AT SIMI VALLEY		FACILITY NUMBER:	565850067
ADMINISTRATOR:	RICE, DOUGLAS		FACILITY TYPE:	740
ADDRESS:	1236 ERRINGER ROAD		TELEPHONE:	(805) 351-8802
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	130	CENSUS: 94	DATE:	02/21/2024
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Brimen Vivar, Administrator		TIME COMPLETED:	04:19 PM

ALLEGATION(S):

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Questionable Death – The death of the resident was due to neglect and lack of supervision.
Neglect/Lack of Care and Supervision – The facility failed to respond to the resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Brimen Vivar and Managing Director Madison Lewis and explained the reason for the visit.

On 04/11/2023, the Department received a complaint regarding Neglect/Lack of Care and Supervision and the Questionable Death of Resident #1 (R1). It was alleged that the facility staff failed to respond to R1 in a timely manner and that there was a concern of questionable death due to neglect/lack of care and supervision. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Lorraine Patterson.

On 04/14/2023, from 12:00 p.m. to 3:15 p.m., LPA Chochian conducted an unannounced complaint visit. During the visit, facility records were requested and reviewed. (continue to LIC9099c)

Substantiated

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: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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-20230411162428

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: 02/21/2024

NARRATIVE

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On 05/18/2023, at approximately 2:35 p.m., Investigator Patterson conducted an interview with R1’s resident representative; on 07/10/2023, from approximately 11:45 a.m. to 1:15 p.m., with the interim Executive Director, staff and residents; on 07/11/2023, at approximately 1:16 p.m., with the Ventura County Medical Examiner Coroner’s office Investigator; on July 13, 2023, from approximately 9:04 a.m. to 5:41 p.m., with staff; and on 07/20/2023, from approximately 2:43 p.m. to 3:52 p.m., with the interim Executive Director and staff. Additionally, Investigator Patterson reviewed Los Robles Hospital Medical Center records, County of Ventura Medical Examiner’s Office Investigative Report #1170-22, death certificate, photos, and facility file documents related to R1.

Facility records reviewed revealed that since 09/07/2021, R1 stayed at the facility at different times on a temporary short-term respite basis. The Physician Report dated 07/22/2022, listed R1’s primary diagnosis as hypertension, hyperthyroid, BPH, and peripheral vascular disease. The secondary diagnosis was listed as Coronary Artery Disease (CAD), cataracts, osteoarthritis, a fall history, and previous head injury. R1 is ambulatory and independently transfers. R1 follows directions and communicates their needs. R1 has the capacity for self-care and medication management. The facility Assessment /Level of Care dated 07/18/2022, documented R1 is an early riser and receives two weeks of respite care. R1 has limited vision and no dietary restrictions, R1 is independent, and bed status is out of bed all day. R1 requires no status checks or assistance with Activities of Daily Living (ADL). R1 walks with a walker and requires grab bars in the bathroom. R1 bathes and performs ADLs and transfers independently. The facility reported no history of falls, and R1 does not require special care.

A review of the facility concierge shift notes for 07/31/22, between 8:00 a.m. and 4:30 p.m., summarized that R1’s resident representative called the facility between breakfast and lunch. R1’s resident representative reported R1 is not answering their phone. The caregivers were paged to check on R1. It was further documented, "We only have two caregivers on the floor!!" "They were tending to other residents," and that a caregiver was sent to R1’s room but there was no answer. "We saw R1 at breakfast but not lunch," and that a caregiver was sent again, knocked and there was no answer, and that the caregiver did not have a key, so the facility had to get a caregiver with a key. At 2:00 p.m., the caregiver went to R1’s room to check on R1 because R1’s resident representative was very concerned that R1 was not answering their phone. The investigation further revealed that R1’s resident representative reported that on the morning and afternoon of 07/31/2022, they alerted the facility’s receptionist on at least two (2) occasions that they were concerned that they could not reach R1. (continue to LIC9099c)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230411162428

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: 02/21/2024

NARRATIVE

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Photos of screen shots of R1’s cell phone showed that R1’s resident representative had attempted to call R1 at 7:27 a.m., 10:01 a.m., 10:39 a.m., and 12:24 p.m. R1 was not checked on until R1 was found in their room at approximately 2:15 p.m., unresponsive with a head injury.

Los Robles Regional Medical center records reflected that on 07/31/2022 at 3:00 p.m., R1 was transported to the hospital via ambulance. Medical records further noted that the R1 was found down with obvious signs of trauma. Staff found R1 in the afternoon covered in feces, urine, and blood. R1 was not responsive, left pupil was larger than the right, abrasions over all four extremities. Moreover, Computed Tomography (CT) scan of the head reported a large left subdural hematoma measuring up to at least 2.1 cm with associated 1 cm of left to right midline shift. Large hematoma in the left frontal region measuring at least 3 cm, moderate bilateral subarachnoid hemorrhage with large amounts of blood. R1 was not intubated due to R1s DNR status. Due to the extensive hemorrhage, trauma surgeon determined that no surgical intervention. R1 was admitted in critical condition and was unstable for transfer. R1 was subsequently placed on comfort measures and passed away on 08/03/2022. The certificate of death revealed the cause of death was intracranial hemorrhage.

Based on the interviews conducted and records obtained during the course of the investigation, the Department determined that there is sufficient evidence to support the allegation of “Neglect/Lack of Care and Supervision: The facility failed to respond to resident in a timely manner” and “Questionable Death due to a lack of neglect and lack of supervision”. Therefore, the allegations are deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. Administrator were informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and 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: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230411162428

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: 02/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/22/2024 Section Cited CCR 87464(f)(1)(5)	1 2 3 4 5 6 7	(f) Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c (5) Regular observation of the resident's physical and mental condition..... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan how you will ensure appropriate resident care and supervision. Submit to CCL by due date. Civil Penalty: An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above.Facility staff failed to assess R1 completely for fall prevention and develop a service plan as R1 had a history of falls, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 02/22/2024 Section Cited CCR 87468.2	1 2 3 4 5 6 7	(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 their individual needs and are delivered by	1 2 3 4 5 6 7	Licensee will submit a plan how you will ensure staff will monitor and respond to residents in a timely manner. Submit to CCL by (date) to prevent civil penalty from accruing.
	8 9 10 11 12 13 14	staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff did not respond to R1 in a timely manor	8 9 10 11 12 13 14	when R1’s resident representative notified the facility multiple times with concerns they could not reach R1. Staff did not check on R1 until R1 was found at approximately 2:15pm unresponsive with a head injury resulting in death, which posed an immediate 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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

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