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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609722
Report Date: 08/15/2023
Date Signed: 08/15/2023 04:04:35 PM

Substantiated


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
04/28/2023 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230428160620
FACILITY NAME:GRANNYS HOMEFACILITY NUMBER:
567609722
ADMINISTRATOR:HERNANDEZ, VICTORFACILITY TYPE:
740
ADDRESS:1831 BERNADETTE STTELEPHONE:
(805) 278-2273
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 6DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Victor HernandezTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision – Facility failed to seek medical attention in a timely manner when facility resident sustained an injury (second degree burn) while in care at the facility.
Neglect/Lack of Care and Supervision – Facility failed to provided supervision when facility resident sustained an injury (second degree burn) while at the facility.
Facility staff did not report serious injury to resident’s responsible party.
Facility staff failed to treat resident with dignity by scolding and yelling at resident.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with licensee/administrator Victor Hernandez and explained the reason for the visit.

On 04/28/2023, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that a lack of care and supervision allowed Resident #1 (R1) to be burned by coffee; facility staff failed to seek treatment for the second-degree burns; and failed to notify R1’s resident representative of the injuries.

(continued on page 2; 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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 7
Control Number 29-AS-20230428160620
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: GRANNYS HOME
FACILITY NUMBER: 567609722
VISIT DATE: 08/15/2023
NARRATIVE
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(continued from page 1; 9099)

On 05/01/2023, from 2:47pm to 4:30pm, Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced initial 10-day complaint visit to the facility. During the visit, LPA Ascencio conducted a physical plant tour at 2:55pm, and obtained pertinent documents. The LPA met with Administrator Victor Hernandez at 3:00pm. The LPA determined further investigation was needed and informed the Administrator the complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Sonia Sandoval.

On 05/09/2023, at approximately 11:34am, Investigator Sandoval conducted an interview with R1’s resident representative; on 05/18/2023, from approximately 10:10am to 12:20pm, with Los Robles Healthcare hospice nurse, R1, facility residents, Administrator, and staff; on 05/31/2023, from approximately 11:55am to 12:35pm, with Staff #1 (S1) and Staff #2 (S2). In addition, Investigator Sandoval reviewed Los Robles Healthcare medical records, text messages from R1’s resident representative pertaining to the incident, photos of R1’s injuries, facility file documents related to R1, and personnel records for S1 and S2.

A review of R1’s Physician Report, dated 04/19/2023, indicated R1 was bedridden with a primary diagnosis of Type II Diabetes Mellitus (DM) with diabetic peripheral angiopathy with gangrene. R1 was unable to manage their own treatment/medication/equipment. R1’s conditions included bowel and bladder impairment, motor impairment/paralysis, had a history of skin condition or breakdown, and required continuous bed care. R1’s mental conditions included confused/disoriented. However, R1 was able to follow instructions and communicate needs. R1 was unable to bathe, dress/groom, feed self or administer their own prescription medications. R1 was receiving hospice care at the time of admission to the facility on 04/20/2023.


(continued on page 3; 9099-C)
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20230428160620
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: GRANNYS HOME
FACILITY NUMBER: 567609722
VISIT DATE: 08/15/2023
NARRATIVE
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(continued from page 2; 9099-C)

The investigation revealed that Los Robles Healthcare hospice treated R1 three times per week on Mondays, Wednesdays, and Fridays, typically in the afternoon. The hospice nurse provided wound care to R1 for the amputated toes on the right foot. On 04/26/2023, between 12:30pm and 2:00pm, the hospice nurse provided wound care and did not observe anything on R1’s arm or torso. The next time the hospice nurse saw R1 was on the next scheduled visit on Friday 04/28/2023, at 10:30am. The hospice nurse began the wound care and skin assessment and immediately noticed the burn on R1’s left forearm. The nurse asked R1 what happened and R1 said R1 burned themself with coffee. The nurse then saw the additional burn on the left side of R1’s torso. The nurse contacted R1’s resident representative to inform of the burns and ask if the facility had notified them of the incident. R1’s resident representative stated the facility did not notify them of the incident. The nurse took pictures of the burns and sent to the hospice supervisor and to R1’s resident representative. The hospice nurse indicated the burn on R1’s forearm was assessed to be a second-degree burn based on the appearance of blistering and the skin was peeling away. The pictures were sent to the hospice Dr. Sherman who confirmed the stage of the burn. The hospice nurse was then ordered to treat the burn in addition to the wound care provided on the subsequent visits. Hospice notes indicate the burn wound on the left torso/rib cage was assessed as closed with a pink wound bed and attached wound edges, no treatment needed.

Information obtained from the staff member statements confirmed that R1 required supervision and assistance while eating. Former staff S1 confirmed on the day of the incident during breakfast, R1 was left unsupervised by S1 while S1 assisted another resident. During that time, R1 spilled coffee on themself and burned their left forearm and torso area with the hot liquid. The Administrator confirmed when they became aware of the incident, they did not seek medical attention for R1 or report the incident to the hospice agency or to R1’s resident representative.


(continued on page 4; 9099-C)
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20230428160620
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: GRANNYS HOME
FACILITY NUMBER: 567609722
VISIT DATE: 08/15/2023
NARRATIVE
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(continued from page 3; 9099-C)

The information obtained during the Department’s investigation found that R1 sustained an injury (second-degree burn) when the facility neglected to provide supervision while R1 ate; failed to seek medical attention in a timely manner; and did not report the serious injury to R1’s resident representative or hospice agency. Therefore the allegations “Neglect/Lack of Care and Supervision – Facility failed to seek medical attention in a timely manner when facility resident sustained an injury (second degree burn) while in care at the facility”; “Neglect/Lack of Care and Supervision – Facility failed to provided supervision when facility resident sustained an injury (second degree burn) while at the facility”; and “Facility staff did not report serious injury to resident’s responsible party” are deemed Substantiated at this time.

Regarding the allegation "Facility staff failed to treat resident with dignity by scolding and yelling at resident", based on interviews with witnesses, S1 was observed scolding R1, shaking their finger at R1 and raising their voice at R1. Based on interviews, this allegation is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20230428160620
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: GRANNYS HOME
FACILITY NUMBER: 567609722
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2023
Section Cited
HSC
1569.312(a)
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§1569.312(a) Basic Services Requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2.
This requirement is not met as evidenced by:
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POC: Licensee will submit a plan how they will ensure 24-hour care and supervision to meet the needs of the residents. Submit to CCL by 08/22/2023.
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Based on interviews, the licensee did not comply with the section cited above. Facility staff failed to supervise R1 while they ate which resulted in R1 spilling coffee and sustaining a second-degree burn, which posed an immediate health and safety risk to residents in care.
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A $500 immediate civil penalty is assessed today.
Type A
08/22/2023
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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POC: Licensee will submit a plan how they will ensure residents will receive medical attention in a timely manner. Submit to CCL by 08/22/2023.

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(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above. Facility staff failed to seek
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medical attention in a timely manner when R1 spilled coffee and sustained a second-degree burn, which posed an immediate health and safety risk to residents in care.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20230428160620
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: GRANNYS HOME
FACILITY NUMBER: 567609722
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2023
Section Cited
CCR
87211(a)(1)(B)
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87211(a)(1)(B) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the
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POC: Licensee will submit a plan on how to meet Reporting Requirements and train caregivers to report incidents immediately to administrator. Submit to CCL by 8/22/2023.
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resident within seven days of the occurrence of any of the events specified in (A) through (D) below… (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
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This requirement is not met as evidenced by:
Based on interviews, the licensee did not comply with the section cited above. Facility staff failed to report R1’s burn injuries to R1’s resident representative and hospice agency, which posed an immediate health and safety risk to residents in care.
Type B
08/22/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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POC: Licensee will conduct personal rights training with all staff and submit evidence of this training to CCL by 8/22/2023.
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This requirement is not met as evidenced by:
Based on interviews, the licensee did not comply with the section cited above. Facility staff was observed yelling and scolding R1, which posed a potential health, safety and personal rights 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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
04/28/2023 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230428160620

FACILITY NAME:GRANNYS HOMEFACILITY NUMBER:
567609722
ADMINISTRATOR:HERNANDEZ, VICTORFACILITY TYPE:
740
ADDRESS:1831 BERNADETTE STTELEPHONE:
(805) 278-2273
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 6DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Victor HernandezTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff did not provide incontinence care to resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with licensee/administrator Victor Hernandez and explained the reason for the visit.

On 5/9/2023, 5/18/2023, and 5/31/2023 CCL Investigations Branch Investigator Sonia Sandoval conducted interviews with witnesses, residents and staff. During those interviews it was stated that staff appeared to keep residents clean and witnesses did not have concerns about the incontinence care provided at the facility. Based on these interviews, the above noted allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report issued to licensee/administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 7