565850141-10-6-2022-29-AS-KBUY-CLNT6P-20221130132725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850141
Report Date: 10/06/2022
Date Signed: 10/06/2022 11:37:50 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
03/28/2022 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20220328145922

FACILITY NAME:	AEGIS LIVING VENTURA		FACILITY NUMBER:	565850141
ADMINISTRATOR:	LANCE SHENK		FACILITY TYPE:	740
ADDRESS:	4964 TELEGRAPH ROAD		TELEPHONE:	(805) 650-1114
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	100	CENSUS: 83	DATE:	10/06/2022
		UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Hannah Robertson, Business Office Manager		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision - Facility employees failed to provide an appropriate level of supervision which resulted in resident #1 (R1) falling and sustaining a fractured wrist

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Business Office Manager Hannah Robertson and Health Services Director Mark Brassfield and explained the reason for the visit.

On 03/28/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Care Supervision. It was alleged that Resident #1 (R1) sustained injuries at the facility due to insufficient staffing. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real.

On 03/29/2022, from 12:59pm to 2:45pm, Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced complaint visit to the facility above. LPA Ascencio conducted an entrance interview with
Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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-20220328145922

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: AEGIS LIVING VENTURA	FACILITY NUMBER: 565850141
	VISIT DATE: 10/06/2022

NARRATIVE

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Administrator Lance Shenk at 1:03 pm. During the visit, the LPA conducted staff interviews, reviewed resident files, obtained copies of pertinent documents, and toured the facility with the Administrator. LPA informed Administrator that the complaint allegation was referred to the Community Care Licensing (CCL) Investigations Branch (IB). The LPA determined further investigation was needed.

On 04/04/2022, Investigator Real conducted a telephonic interview with R1’s resident representative; on 04/22/2022, attempted to conduct an interview with R1, however, due to R1’s recollection, was unable to provide any information for the pending investigation; on 04/28/2022, conducted a telephonic interview with R1’s resident representative; on 06/13/2022, conducted a telephonic interview with R1’s occupational therapist; and on 06/14/2022, conducted interviews with facility employees and residents. Additionally, Investigator Real requested and reviewed Ventura County Medical Center Hospital medical records and facility file documents including incident reports, progress notes and staff schedule.

On 12/07/2021, R1 was admitted to the memory care portion of the facility with a history of falls including a fall with injury to head while living at R1’s previous facility. R1 was noted as being on an anticoagulant (Warfarin). A review of the incident reports found that R1 had one witnessed fall on 12/12/2021 and one unwitnessed fall on 03/06/2022. The staff schedule reviewed indicated there was adequate staffing.

On 12/12/2021, at 8:11am, while in R1’s bedroom, staff assisted R1 to stand and start walking with walker while the staff made the bed. R1 lost balance and fell. R1 sustained a skin tear the size of a quarter on right elbow, the wound was cleaned and bandaged by the med tech. The facility nurse assessed R1, noted no head injury and determined no further medical attention was required. R1’s doctor and resident representative were notified.

On 12/15/2021, R1 was noted to have a change of condition. R1 appeared weak and lethargic. R1 was then sent to the hospital and admitted. According to the hospital records, R1 identified with a history of prior falls and prior compression fractures. It was reported R1 has a witnessed fall at the
Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220328145922

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: AEGIS LIVING VENTURA	FACILITY NUMBER: 565850141
	VISIT DATE: 10/06/2022

NARRATIVE

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facility on 12/12/2021 without head trauma. It was noted R1 also had a fall with injury to head prior to this fall while living in another facility. R1’s history noted R1 as being on an anticoagulant (Warfarin). R1 was diagnosed with intraparenchymal hemorrhage and midline shift. Neurosurgery was consulted and suspected an amyloid stroke. R1 was discharged from the hospital back to the facility on 12/23/2021. No abuse or neglect concerns were noted in the hospital records.

On 03/06/2022, approximately 1:00pm, R1 had an unwitnessed fall in the common area of the facility. Staff had gone to clear the courtyard gate and when they returned found R1 on the ground. Staff stated they believed R1 had attempted to walk because of the distance R1 was from the chair in the common area. The medication manager and nurse were called to the area. 911 was also called due to R1 had a bump on right side of head and pain in right arm. R1 also had a skin tear on right arm near elbow. R1’s Primary Care Physician and resident representative were notified of the fall. R1 was taken to the hospital and admitted. A CT scan of R1’s head found a right frontal scalp hematoma. An X-ray of R1’s right forearm identified a fracture of the distal radial metaphysis and mildly displaced distal ulnar metaphyseal fracture. R1 was discharged from the hospital on 03/14/2022. No abuse or neglect concerns were noted in the hospital records.

During the course of the investigation, it was revealed that R1 fell and sustained visible injuries to head just prior to moving into the Aegis Facility. Shortly after moving into the facility, R1 had a witnessed fall 12/12/2021 in their room and did not hit their head but was diagnosed with a brain bleed. In March (03/06/2022) R1 had a second fall which resulted in a brain bleed and a fractured wrist. None of the persons interviewed observed any neglect or lack of supervision. The facility documented both falls and copies of the incident reports were obtained. The facility employees denied the allegation and reported the staffing levels in the memory care unit allow them to provide an appropriate level of care and supervision for the residents. The information and evidence obtained during the investigation did not sufficiently support the allegation, therefore the allegation “Neglect/Lack of Care and Supervision – Facility employees failed to provide an appropriate level of supervision which resulted in resident #1 (R1) falling and sustaining a fractured wrist” is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

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