565850067-2-11-2022-29-AS-JAPL-CEU38N-20220527180149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850067
Report Date: 02/10/2022
Date Signed: 02/11/2022 04:59:55 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
01/25/2022 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20220125164008

FACILITY NAME:	VISTA AT SIMI VALLEY		FACILITY NUMBER:	565850067
ADMINISTRATOR:	CAROL ANN LEROSE		FACILITY TYPE:	740
ADDRESS:	1236 ERRINGER ROAD		TELEPHONE:	(805) 351-8802
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	130	CENSUS: 52	DATE:	02/10/2022
		UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Carol Ann LeRose		TIME COMPLETED:	04:02 PM

ALLEGATION(S):

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Staff are not responding timely to calls for assistance.
Resident's room was unsafe.
Resident's room was not clean.
Resident's room was in disrepair.

INVESTIGATION FINDINGS:

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Substantiated

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: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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 4

Control Number 29-AS-20220125164008

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: 02/10/2022

NARRATIVE

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continued from 9099:

Based on interviews and photographic evidence, resident 1 (R1's) bathroom door had been left unrepaired with screws protruding from the door hinges. R1 indicated the door was in disrepair for a month and that it was reported to caregivers multiple times. The facility maintenance system did not reflect this as being reported. R1 stated the caregivers did not report the door problem to maintenance. Once the maintenance director was informed of the issues with the door it was repaired. LPAs observed the door still did not close properly so the door could not be locked. R1 stated this was reported to caregivers multiple times. Therefore, the allegations a resident's room was unsafe and in disrepair is substantiated.

At approximately 11:03 a.m. LPAs observed a soiled diaper on R1's bathroom floor which was left there by R1 prior to showering unassisted. LPA observed the soiled diaper was in the same location at 02:28 p.m. Resident Care Director Brimen Viver indicated R1's caregiver should have removed all trash from the room. Therefore, the allegation that a resident's room was not clean is substantiated.

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 emailed to the administrator.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
01/25/2022 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20220125164008

FACILITY NAME:	VISTA AT SIMI VALLEY		FACILITY NUMBER:	565850067
ADMINISTRATOR:	CAROL ANN LEROSE		FACILITY TYPE:	740
ADDRESS:	1236 ERRINGER ROAD		TELEPHONE:	(805) 351-8802
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	130	CENSUS: 52	DATE:	02/10/2022
		UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Carol Ann LeRose		TIME COMPLETED:	04:02 PM

ALLEGATION(S):

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Urine on the bathroom floor in resident's room in memory care.
Residents' laundry is not being done.
Facility is malodorous.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Teresa Camara and Elsie Campos conducted a subsequent complaint visit. LPAs arrived at the facility at 10:03 a.m. LPAs met with Business Office Manager Debbie Doering and explained the reason for the visit. LPA later met with administrator Carol Ann LeRose.

LPAs conducted a tour of the facility starting at 10:06 a.m. LPAs inspected all memory care rooms and a sampling of assisted iving rooms both upstairs and downstairs. LPAs conducted interviews with residents at 10:08 a.m. and 10:58 a.m. LPAs interviewed staff at 10:43 a.m. LPAs did not observe urine on any bathroom floors. One resident had an accident in their room but the room was in the process of being cleaned when LPAs arrived. LPAs did not observe any malodorous conditions at the facility. LPAs did not observe any laundry piled up and based on resident and staff interviews, the laundry is done on a schedule. Therefore, the allegations of urine on the bathroom floor, the facility being malodorous and the laundry not being done is unsubstantiated at this time. Exit interview conducted. Today's reports was discussed and issued.

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: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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 4

Control Number 29-AS-20220125164008

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: 02/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/17/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (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	1 2 3 4 5 6 7	Administrator will provide a written plan for more timely response times to calls for assistance and provide the plan to CCL on or before 2/17/22.
	8 9 10 11 12 13 14	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 and record review, response times to calls for assistance have taken over an hour in some instances, which	8 9 10 11 12 13 14	poses/posed a potential health, safety or personal rights risk to persons in care.
Type B 02/17/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities, (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	LPA observed the bathroom door was repaired during the visit. Administrator will provide evidence of staff training on ensuring residents' rooms are clean and free of obstructions. Documentation of this will be provided to CCL on or before 2/17/22.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on LPAs observations, resident interviews, and photographic evidence, R1's room was unsafe due to protruding screws (photograph), the bathroom door does not close/lock properly, the motion sensor does not work properly, and the bathroom had trash on the floor not picked up when staff visited	8 9 10 11 12 13 14	the room, which poses/posed a potential health, safety or personal rights risk to persons 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4