565850292-12-19-2022-29-AS-JAPL-CMHNKE-20221227093146

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850292
Report Date: 12/17/2022
Date Signed: 12/19/2022 09:27:48 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
12/12/2022 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20221212155700

FACILITY NAME:	BLUEBIRD HOME		FACILITY NUMBER:	565850292
ADMINISTRATOR:	CATABAY, TEDDY		FACILITY TYPE:	740
ADDRESS:	1484 BLUEBIRD AVE		TELEPHONE:	(805) 827-3651
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 5	DATE:	12/17/2022
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Arlene Martinez		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide residents medication as prescribed.
Staff did not provide adequate care services to resident while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct an initial 10 day visit. The LPA was greeted by staff at 11:06 a.m. The staff contacted the Licensee Arlene Martinez on the phone. The LPA spoke with the licensee on the phone at 11:15 a.m., and explained the reason for the visit.

During today's visit, the LPA interviewed staff, administrator, and residents from11:10 a.m. to 2:00 p.m., and conducted record review at 12:48 p.m.

Continues on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2022

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 3

Control Number 29-AS-20221212155700

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: BLUEBIRD HOME	FACILITY NUMBER: 565850292
	VISIT DATE: 12/17/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On the allegation that ‘Staff did not provide residents medication as prescribed’, it is the Reporting Party’s (RP) concern that the facility staff did not provide Resident #1(R1) with the prescribed medication, consequently R1 was observed experiencing pain. Interviews with the RP revealed that on 12/08/2022 the hospice nurse placed an order(prescription) for pain medication for R1, because R1 was experiencing more pain, and the over the counter medication was not effective to control the pain. As of 12/09/2022 the prescribed pain medication was available for facility staff to assist the R1 to take it, when in pain. Per the RP , the R1 was not alert to take the medication. LPA Urena interviewed staff about assisting R1 with pain medication. Staff sated that they could not assist the resident with the medication because the R1 did not want to take it. Staff stated that the hospice nurse would administer R1 with the pain medication during the visits. Staff stated that on 12/11/2022 at approximately 10:30 p.m., they called the licensee to inform them that R1 was in pain, and screaming when R1 would move. Staff stated that R1 refused to take the pain medication. Per the staff, on 12/12/2022 the hospice nurse arrived at the facility at approximately 10:30 a.m.; attempted to administer the pain medication to R1 at approximately 11:30 a.m., but R1 refused it; consequently, the nurse crushed the pill, put it in apple sauce, and fed it to R1. Record review of the medication log indicates that the prescribed pain medication was administered to R1 by the hospice staff on 12/09/2022 at approximately 6:40 p.m., on 12/10/2022 at 3:52 p.m., and 7:50 p.m., and on 12/12/2022 at 11:30 a.m. The staff stated that they could not assist with the prescribed pain medication, because the R1 was unable to take it themselves. The LPA interviewed the administrator about staff assisting R1 with the pain medication, and the administrator sated that they had informed the hospice nurse that staff could not administer the prescribed medication.

Based on the interviews, and record review, there is insufficient evidence to support the allegation that ‘Staff did not provide residents medication as prescribed’, therefore this allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20221212155700

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: BLUEBIRD HOME	FACILITY NUMBER: 565850292
	VISIT DATE: 12/17/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On the allegation that ‘Staff did not provide adequate care services to resident while in care’, it is the RP's concern that R1 was not turned by staff, and was often left in soiled diapers. LPA Urena interviewed the RP and they stated stated that they had not observed the allegation first-hand, but that they were informed about the soiled diapers by another hospice staff member. To investigate this allegation LPA Urena interview staff about the schedule they follow to ensure that residents are kept dry, and comfortable throughout the day and night. The staff interview revealed that they change residents’ diapers any time the residents request to be changed, and check residents every two hours during the day and night. The first diaper change is between 6:30 a.m. to 7:00 a.m. and last diaper change is in the evening between 8:30 p.m. and 9:00 p.m. LPA Urena interviewed residents, and the residents’ interviews revealed that the staff take care of the diaper change often enough to keep them comfortable, and any time they need to be changed. Residents stated that staff assist them with moving in, and out of the bed and to change positions when they request it.

Base on the interviews and information obtained, and although the allegation may have happened, there is insufficient evidence to support the claim that ‘Staff did not provide adequate service to resident while in care’. Therefore, this allegation is deemed Unsubstantiated at this time.

No citations were issued. The report was reviewed with the licensee over the phone and the licensee's representative signed the report. The report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3