565850237-3-20-2023-29-AS-JAPL-CQ7P9J-20230323110713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850237
Report Date: 03/20/2023
Date Signed: 03/20/2023 05:03:55 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
12/14/2022 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20221214083721

FACILITY NAME:	BLISSFUL GRANNIES HOME		FACILITY NUMBER:	565850237
ADMINISTRATOR:	UDDEN, JOHNNA		FACILITY TYPE:	740
ADDRESS:	3704 MONTE CARLO DRIVE		TELEPHONE:	(805) 985-4538
CITY:	OXNARD	STATE: CA	ZIP CODE:	93035
CAPACITY:	6	CENSUS: 6	DATE:	03/20/2023
		UNANNOUNCED	TIME BEGAN:	03:24 PM
MET WITH:	Johnna Udden		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Resident sustained questionable injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced subsequent complaint visit to this facility. LPA initially met with staff who called the administrator Johnna Udden. LPA met with the administrator at 4:00 p.m. and explained the reason for the visit.

On 12/14/2022, the Department received a complaint alleging resident 1 (R1) sustained a questionable injury while in care. Specifically, R1 was found to have brusing on their face reportedly due to a fall in the bathroom, however it was assumed that staff did not take R1 into the bathroom which made the injury seem questionable.

(continued on 9099-C)

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: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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-20221214083721

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: BLISSFUL GRANNIES HOME	FACILITY NUMBER: 565850237
	VISIT DATE: 03/20/2023

NARRATIVE

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On 12/21/2022, LPA Camara conduct an intial complaint investigation visit to the facility and conducted a brief tour of the facility at 2:45 p.m. LPA conducted records review at 2:55 p.m. and obtained copies of pertinent documents. LPA conducted interviews with staff and residents between 3:05 p.m. and 4:15 p.m.

On 3/15/2023, LPA conducted a telephone interview with former staff. On 3/17/2023, LPA conducted a telephone interview with a witness.

Facility records showed R1 was receiving hospice care. On 12/21/2022, LPA had attempted to speak with R1, however R1's condition prevented a successful interview. LPA observed R1 was on the couch watching television with other residents. R1 would frequently scream as if in distress and would frequently yell "ouch" although nobody was near them. Staff would sit with R1 to provide comfort. During an interview with another resident, resident 2 (R2), they indicated staff at the faciltiy provide excellent care and they are very caring and patient with R1. R2 had no concerns about the care provided at the facility.

During interviews with staff, they stated on the date of the accident, 12/10/2022, R1 required incontinence care so two staff took R1 into the bathroom to get cleaned up. One staff left the bathroom to attend to another resident and during that time R1 fell forward off of the toilet and hit their forehead on the handrail directly across from the toilet. Staff was able to get R1 back on the toilet. Staff stated R1 had a bump on their head and bruising. The bruising eventually made its way down to R1's eyes and then down R1's face.

The administrator and licensee stated they consulted with a hospice nurse regarding the bruising since it was concerning that the bruising traveled down R1's face but the hospice nurse told them it was normal for that type of injury. LPA interviewed a hospice nurse who confirmed the bruising process was normal for that type of injury. The nurse stated they did not realize facility staff cleaned R1 in the bathroom until after the incident and they understood the mechanism of injury.

Based on the information obtained during interviews and document reviews, the Department does not have sufficient evidence to support the above allegation. Therefore, the allegation "Resident sustained questionable injury while in care" is deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided 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: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC9099 (FAS) - (06/04)

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