565850188-9-25-2024-29-AS-KHEN-D9FTVB-20240925150341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850188
Report Date: 09/05/2024
Date Signed: 09/25/2024 01:37:38 PM

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
08/28/2024 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20240828155048

FACILITY NAME:	2592 CIRO LLC		FACILITY NUMBER:	565850188
ADMINISTRATOR:	SARREAL, JOVY		FACILITY TYPE:	740
ADDRESS:	2592 CIRO AVE		TELEPHONE:	(805) 807-0663
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 4	DATE:	09/05/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Jovy Sarreal & Gilliana Sherman		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Facility staff did not follow physician's orders

INVESTIGATION FINDINGS:

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Please note: this is an amendment to the original report issued, as the allegation was incorrectly written.

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation regarding the above noted allegation. LPA initially met with facility staff and explained the reason for today's visit. Administrator Jovy Sarreal and Licensee Gilliana Sherman arrived at the facility shortly after the visit began. Entrance interview conducted.
During today's visit, LPA interviewed Administrator at 10:00AM, reviewed Resident #1 (R1)'s file and obtained copies of pertinent documents, LPA conducted a facility tour at 10:44AM, and interviewed 2 (two) staff beginning at 02:10PM. The following was then determined:
The complaint alleges that facility staff did not follow physician's orders related to repositioning R1. LPA reviewed R1's file which indicates that R1 was admitted to the facility on 07/26/2024. Interview and record review revealed that R1 was on hospice and had existing pressure injuries/wounds upon admit to the facility. 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: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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-20240828155048

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: 2592 CIRO LLC	FACILITY NUMBER: 565850188
	VISIT DATE: 09/05/2024

NARRATIVE

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Although R1's hospice agency took the hospice plan of care and binder from the facility after R1 passed, LPA was able to review Progress Notes for R1. Progress notes indicate that R1's hospice nurse indicated they would contact a wound specialist on 08/14/2024. However, interview revealed that the wound specialist did not make it to the facility before R1 passed away. An unstageable sacral wound was noted on 08/19/2024 and on 08/20/2024, R1's physician ordered "patient to be repositioned on her side every 2 hours." Interview with staff revealed that R1 was repositioned every 2 hours during the day when staff provided incontinence care. Staff indicated there was a log filled out each time they repositioned the resident. However, the hospice agency removed the log from the facility, so LPA was unable to review the document. R1's overall condition worsened and R1 passed away under hospice care on 08/22/2024. LPA attempted to contact R1's hospice agency to discuss the allegation and to obtain pertinent documents, however, LPA did not receive a response. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "facility staff did not follow physician's orders" is deemed UNSUBSTANTIATED at this time.

No deficiencies cited. 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: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC9099 (FAS) - (06/04)

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