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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850093
Report Date: 03/06/2023
Date Signed: 03/06/2023 10:07:54 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
11/10/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20221110164437
FACILITY NAME:VENTURA VILLA ASSISTED LIVINGFACILITY NUMBER:
565850093
ADMINISTRATOR:WARD-MICHAYLUK, EVANGELINEFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA ROADTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: ZIP CODE:
93003
CAPACITY:49CENSUS: 16DATE:
03/06/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Endy Guadarrama, Administrative AssistantTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff failed to provide timely medical attention
Lack of supervision resulted in fracture
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to issue the findings for the above allegations. The LPA met with staff Endy Guadarrama and explained the reason for the visit.

On 11/10/2022, the Department received a complaint, which alleged that staff failed to seek timely medical attention for Resident #1 (R1) after R1 suffered a fall. Community Care Licensing Division’s Investigation’s Branch (IB) Investigator Heidy Bendana was assigned to the case. On 11/15/2022, the LPA conducted the initial visit, and the LPA toured the facility, reviewed video footage at 11:55 a.m., and interviewed staff at 9:35 a.m., 9:50 a.m., 11:11 a.m., and 11:40 a.m. Investigator Bendana obtained facility video footage on 12/08/2022, interviewed three (3) staff members on 12/08/2022, interviewed R1’s responsible party on 1/12/2023 and 1/24/2023; interviewed a hospice nurse on 1/12/2023; and, interviewed two (2) staff members on 1/12/2023. Investigator Bendana obtained and reviewed medical records pertinent to the case.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
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-20221110164437
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: VENTURA VILLA ASSISTED LIVING
FACILITY NUMBER: 565850093
VISIT DATE: 03/06/2023
NARRATIVE
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CONT - PAGE 2

Regarding the allegation: Staff failed to provide timely medical attention

It was alleged that staff failed to obtain timely medical attention for R1. Records review revealed that R1 was admitted to the facility on 07/05/2022 with hospice services, with the admitting diagnosis of metastatic cancer, hypertension, and dementia. Prior to admission to the facility, R1 was hospitalized and was diagnosed with lung cancer that had metastasized to the bone. Medical records indicated that R1 had multiple malignant masses throughout R1’s right lung, one of which that had progressively increased in size. As a result, R1’s appraisal dated 07/10/2022 noted that R1 was in ‘constant pain’ due to the masses.



The investigation revealed that R1 suffered an unwitnessed fall in the facility courtyard on 11/05/2022. The staff whom assisted R1 after R1’s fall claimed that R1 was checked for immediate injuries and then placed back in their wheelchair. Staff mentioned that R1 sustained a cut on their forehead and mentioned that R1’s forehead hurt. Another staff whom assisted R1 indicated that R1 complained of hip pain. Staff reported that they informed the House Manager via phone and left a handwritten note, indicating that R1 had fallen. Interviews with the House Manager confirmed that staff had called them the evening of 11/05/2022 and reported R1’s fall; yet, the House Manager admitted that they notified the hospice agency and R1’s responsible party of R1’s fall the next morning, 11/06/2022. Staff indicated that they had assumed that R1 was ‘ok’ and did not require immediate medical attention.

A hospice nurse assessed R1 on 11/06/2022. Interviews with the hospice nurse revealed that R1’s vitals and heart was checked. Although the nurse claimed that they checked R1’s range of motion, additional witnesses stated that R1 had complained of hip pain during the assessment. The information obtained from the hospice nurse supported claims that they recalled R1 expressing pain; however, they did not recall where the pain was located. The LPA also reviewed facility charting notes regarding R1. It was documented on 11/06/2022 that R1 ‘had some swelling on [R1’s] left temple area and scrape… no visible injuries on [R1’s] body but appears to have pain on [R1’s] left side, left shoulder particularly.’ Staff interviews and R1’s appraisal dated 07/10/2022 stated that R1 was ‘always’ in pain due to R1’s tumor. R1’s responsible party indicated that R1’s cancer was in their chest and had spread to their lungs. Yet, records review and interview revealed that R1’s hip pain was unrelated to R1’s cancer diagnosis. Records and interviews confirmed that R1 suffered another unwitnessed fall in R1’s room on either 11/06/2022 or on 11/07/2022 at approximately 4:00 a.m.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20221110164437
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: VENTURA VILLA ASSISTED LIVING
FACILITY NUMBER: 565850093
VISIT DATE: 03/06/2023
NARRATIVE
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CONT - PAGE 3

R1 was placed back into bed. Staff claimed R1 was ‘crying in pain’ when R1 lifted their arms and chose to contact hospice. Whereas hospice wanted to send a nurse, staff indicated that R1’s responsible party wanted R1 to be sent to the hospital. On 11/07/2022, R1’s responsible party took R1 to the hospital. Upon admission to the hospital, it was discovered that R1 sustained a left hip fracture. R1 did not return to the facility.

Based on the investigation, there is sufficient evidence to support claims that the facility failed to provide timely medical attention for R1. R1 suffered two unwitnessed falls and complained of pain. Facility staff felt they fulfilled their due diligence by contacting the hospice agency regarding R1’s fall. As directed per regulation, the facility is expected to notify R1’s hospice agency instead of calling 9-1-1 if R1 was experiencing an emergency that was directly related to the expected course of R1’s terminal illness. R1 was receiving hospice services due to their terminal diagnosis of cancer and dementia. R1 fell on two occasions and was experiencing hip pain. This pain was not directly related to the reason as to why R1 was admitted to hospice. The allegation, ‘staff failed to provide timely medical attention’ was Substantiated at this time.

Regarding the allegation: Lack of supervision resulted in R1 sustaining a fracture

It was alleged that staff failed to supervise R1, which resulted in R1 falling and sustaining a fracture. Records review revealed that R1 was admitted to the facility on 07/05/2022 with hospice services, with the admitting diagnosis of metastatic cancer, hypertension, and dementia. R1’s physician’s report dated 7/7/2022 stated that R1 had an unsteady gait, had auditory and visual impairment, needed assistance to transfer to and from bed, exhibited confusion and wandering behavior, and required assistance with all aspects of care besides feeding oneself. Staff claimed that R1 ambulated with a wheelchair and stated they would have to remind R1 to utilize their wheelchair when ambulating through the facility. Staff stated that R1 would oftentimes get out of their wheelchair and use it as a walker. Medical records dated 07/01/2022 indicated that prior to R1 being admitted to the facility, R1 was deemed a fall risk due to R1’s mental status and condition.



R1 suffered an un-witnessed fall in the facility courtyard on 11/05/2022. Staff interviews stated that R1 would regularly sit out on the courtyard after dinner. Staff claimed when they put R1 out on the courtyard, they told R1 ‘not to get up’ and said they left R1 alone because there were cameras in the courtyard.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20221110164437
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: VENTURA VILLA ASSISTED LIVING
FACILITY NUMBER: 565850093
VISIT DATE: 03/06/2023
NARRATIVE
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CONT - PAGE 4

A review of facility camera footage confirmed that at approximately 4:48 p.m. on 11/05/2022, R1 was observed sitting in their wheelchair in the courtyard .R1 was observed to be alone, and the footage did not capture staff ‘making rounds’ or checking in on R1. The camera footage skips to 5:48 p.m., where R1 is seen laying on their side in the courtyard, shoes scattered above their head, and two caregivers were lifting R1 up into the wheelchair. As the camera footage jumps from the time stamp of 4:48 p.m. to 5:48 p.m., one is unable to determine the time in which R1 fell, or the time that staff found R1 on the ground. Records and interviews confirmed that R1 suffered another un-witnessed fall in R1’s room on either 11/06/2022 or on 11/07/2022 at approximately 4:00 a.m. R1 was placed back into bed.

Per the interviews conducted, there was no indication that staff implemented any fall precautions to decrease the likelihood of R1 suffering a fall at the facility. Although the Administrator claimed that R1 had a pendant and call button to ask for assistance, the investigation revealed that R1 did not wear a pendant while residing at the facility. There was no additional evidence to confirm whether R1 had a fall mat, bed alarm, or other fall prevention measures in place. Whereas the Administrator indicated that the facility did not provide 1:1 care, information obtained from other staff interviews revealed that staff believed that R1 either required 24-hour supervision, or 1:1 care. Whereas R1’s hospice nurse did not deny R1’s need for 1:1 care, it was communicated that R1 did not ‘necessarily need’ 1:1 care. R1’s family member also indicated that R1 required 1:1 care but knew R1 was not receiving 1:1 care when R1 resided at the facility.

Based on the information obtained in interviews, observations, and records review, there is sufficient evidence to support the claim that due to lack of supervision, R1 suffered a fall and subsequently sustained a fracture. Staff stated they left R1 in the courtyard alone because there were ‘cameras in the courtyard’. Multiple staff stated that R1 either required 1:1 care or 24-hour care. Lastly, the facility did not implement fall preventative measures to lessen the likelihood of R1 sustaining a fall. This allegation is deemed Substantiated at this time.
Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. A copy of the report was issued, along with appeal rights.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20221110164437
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: VENTURA VILLA ASSISTED LIVING
FACILITY NUMBER: 565850093
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2023
Deficiency Type
POC Due Date /
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DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/08/2023
Section Cited
CCR
87469(c)(3)
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87469(c)(3) Advanced Directives and Requests Regarding Resuscitative Measures. … For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit a Statement of Understanding, explaining the steps the facility will follow to avoid similar issues from happening again and to ensure compliance to Title 22 Regulations regarding emergency medical assistance for residents receiving hospice services.
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Based on the investigation, the licensee did not comply with the section cited above, as the facility did not call 9-1-1 and instead called R1's hospice agency after R1 fell and was in pain, even though the pain was unrelated to the terminal illness, which poses an immediate health and safety risk to residents in care.
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Request Denied
Type A
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Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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The Administrator agreed to do the following:
1. Submit a Plan of Action, detailing how staff are trained to respond to resident falls (witnessed and unwitnessed). In addition, detail the facility's protocol surrounding fall prevention. Submit protocol to CCL no later than 03/08/2023.
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This requirement is not met as evidenced by:
Based on the investigation, licensee did not comply with the section cited above, as staff did not provide adequate supervision, resulting in R1 falling and sustaining injuries, which poses an immediate health and safety risk to residents in care.
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2. Review the protocol with all staff. Submit the sign-in sheet and all applicable documents to CCLD no later than 03/13/2023.

A civil penalty in the amount of $500 is assessed.
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: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5