565850067-6-2-2023-29-AS-DPEA-CX4Q39-20231030114818

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850067
Report Date: 05/12/2023
Date Signed: 06/02/2023 08:27:12 AM

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
01/19/2022 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20220119094655

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: 83	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Brimen Vivar		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Facility failed to provide proper hygiene/bathe resident
Facility failed to provide proper incontinence care
Facility failed to request emergency medical services in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with Administrator Brimen Vivar and explained the reason for the visit.

During LPA's initial investigation visit on 5/17/2022, LPA reviewed records at 11:00 a.m. and spoke with staff at 10:34 a.m. and 11:38 a.m. During today's visit LPA interviewed staff at 1:00 p.m. and 1:50 p.m. LPA reviewed and obtained pertinent records.

(continued on 9099-C, page 2)

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: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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-20220119094655

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: 05/12/2023

NARRATIVE

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(continued from 9099, page 1)

Regarding the allegations R1 was not being provided proper incontinence care or bathing:
LPA interviewed staff who confirmed R1 was resistant to being provided incontinence care and bathing. Staff indicated, even when R1 had been moved into memory care, R1 would use the call pendant to request assistance in the bathroom. Staff would assist R1 with incontinence care in the bathroom. When R1's health began to decline R1 resisted assistance in the bathroom and R1 preferred to be changed in bed. In addition, R1's staff indicated R1 did not like to be showered and resisted assistance in the shower. R1 would be given sponge baths and staff would ensure R1's skin was intact when giving incontinence care and sponge baths. One staff in particular was able to get R1 in the shower occasionally but even that staff indicated it could be difficult because R1 did not like the water. Based on interviews with staff, the allegations R1 was not being provided proper incontinence care or bathing is deemed Unsubstantiated at this time.

Regarding the allegation the facility failed to call emergency services in a timely manner for R1:
LPA interviewed staff who stated during that time they were checking memory care residents three times daily for fever. When R1 showed they had a fever they checked R1's oxygen level and pulse. Based on results, staff called 9-1-1. Based on this information, the allegation staff failed to call emergency services in a timely manner is deemed Unsubstantiated at this time.

No deficiencies observed. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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