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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850281
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:11:04 PM


Document Has Been Signed on 09/12/2024 03:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:NAVITA RESIDENCES TULLFACILITY NUMBER:
565850281
ADMINISTRATOR:VIJAYAKUMAR, KARTHIGAFACILITY TYPE:
740
ADDRESS:5603 TULL STTELEPHONE:
(805) 494-4121
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 6DATE:
09/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Karthik "Raj" KanakarajTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent Case Management-Incident visit. The purpose of the visit is to issue final findings related to the Case Management-Incident visit initiated by LPA Zabel Chochian on 03/20/2024. LPA Camara met with administrator Karthik Kanakaraj. Entrance interview conducted.

On 03/15/2024, the Department received an incident report, noting that on 03/08/2024, Resident #1 (R1) suffered a fall in their private room, which resulted in a fractured hip and hospitalization. On 03/20/2024, from 3:00 p.m. to 5:00 p.m., LPA Zabel Chochian conducted a Case Management - Incident visit to the facility. During the visit, LPA Chochian and staff toured the facility at 3:15 p.m.; the LPA conducted a file review at approximately 3:30 p.m. and obtained pertinent documentation related to R1; and interviews with staff and the Administrator were held regarding the incident at approximately 4:00 p.m. The LPA determined further investigation was needed and informed the Administrator that the case was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Dennis Seng.

On 05/15/2024, at approximately 10:45 a.m., Investigator Seng conducted an interview with R1’s resident representative; on 05/16/2024, from approximately 4:02 p.m. to 5:35 p.m., with staff, Administrator, and residents; on 07/11/2024, contacted Ventura Police Department (VPD) and was informed there was no incident report taken or on record for R1. In addition, Ventura Community Memorial Hospital (VCMH), Victoria Care Center, and Viva Home Health medical records and facility file documents related to R1 were reviewed.

According to R1’s Preplacement Appraisal Information, R1 was diagnosed with schizophrenia. R1 was unable to manage their own treatment and has a mild cognitive delay. It lists R1 as unable to walk without any physical assistance. R1 is unable to use evacuation routes including stairs and is unable to quickly
(continued on LIC809C)
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NAVITA RESIDENCES TULL
FACILITY NUMBER: 565850281
VISIT DATE: 09/12/2024
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(continued from LIC809)
evacuate. Per R1’s Physician Report, dated 09/19/2023, R1 also has unspecified dementia, and was listed
as non-ambulatory. Under the Medical Emergencies portion of when to call 911, it states if a resident has fallen and may have broken bones, to call 911. Per R1’s Needs and Services Plan and Resident Appraisal, dated 09/07/2020, it shows R1 was diagnosed with COPD, Alzheimer’s disease, schizophrenia, hypertension, and dementia.

The VCMH medical records revealed R1 was brought in by ambulance to the emergency room on 03/09/2024 at approximately 8:39 a.m. with the chief complaint of left hip pain. The records documented R1’s “pain is currently rated a "7/10" in severity. Patient’s increasing pain prompted today's Emergency Doctor’s visit for further evaluation.” The records further documented R1 sustained a left femoral neck fracture (hip fracture) after a mechanical fall when tripping over a wheelchair at their assisted living facility. R1 underwent left proximal femur open reduction and placement of a cephalomedullary nail with orthopedic surgery on March 9, 2024. On 03/14/2024, R1 was discharged to Victoria Care Center for further rehabilitation.

Based on files reviewed and interviews conducted, the Department found sufficient evidence to prove that the facility was responsible for the neglect and lack of care and supervision of R1 by failing to contact medical services in a timely manner. This caused R1 to experience extended pain. R1 sustained a broken left hip from a fall dated 03/08/2024 at approximately 11:30 p.m. Facility staff both admitted to not calling 911 or notifying the Administrator of R1’s fall until the following morning on 03/09/2024 at approximately 8:00 a.m. Once the Administrator was notified of the fall, they immediately called 911 and notified R1’s resident representative. R1 was not taken to Ventura Community Hospital until 03/09/2024, at approximately 8:38 a.m. The facility staff both stated that the fall occurred at approximately 11:30 p.m. on 03/08/2024. They both admitted they should have notified the Administrator of the fall immediately and called 911 to have R1 checked, as R1 stated R1 was experiencing pain on their left hip immediately after the fall and complained of pain on several occasions throughout the night. Based on the evidence received from the facility staff, and the medical records; the department has sufficient evidence to determine that the facility staff did not obtain timely medical attention for R1.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D).
Exit interview conducted, appeal rights provided, a copy of this report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/12/2024 03:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: NAVITA RESIDENCES TULL
FACILITY NUMBER: 565850281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2024
Section Cited
CCR
87465(g)

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87465 Incidental Medical and Dental Care (g)The licensee shall immediately telephone 9-1-1 if an injury... has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis… This requirement is not met as evidenced by:
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Licensee will submit a plan how they will ensure residents receive timely medical care. This plan must be submitted to CCL by 9/16/2024.
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Based on interviews and records, licensee did not comply with the section cited above as facility staff did not seek timely medical care after R1 fell and complained of left hip pain, causing R1 to experience extended pain from the hip fracture, which posed an immediate health and safety risk to residents in care.
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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: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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