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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609938
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:15:22 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
07/28/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20230728084857
FACILITY NAME:RESIDENTIAL FIRST CARE, LLCFACILITY NUMBER:
567609938
ADMINISTRATOR:MEDINA, LIDIAFACILITY TYPE:
740
ADDRESS:6109 VERA STTELEPHONE:
(805) 842-1679
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 6DATE:
01/19/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lidia MedinaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Neglect/Lack of Supervision: Staff failed to supervise Resident #1 (R1) resulting in R1 sustaining a fracture from a fall while in care.
Facility staff are not providing adequate supervision to residents in care.
Facility staff left resident in a soiled diaper for a long period of time.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPAs met with Administrator, Lidia Medina, and explained the reason for the visit.

On 07/28/2023, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that the facility staff failed to provide supervision to Resident #1 (R1) resulting in R1 falling and sustaining a hip fracture. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Heidy Bendana.

(Report Continued on LIC 9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
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 5
Control Number 29-AS-20230728084857
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: RESIDENTIAL FIRST CARE, LLC
FACILITY NUMBER: 567609938
VISIT DATE: 01/19/2024
NARRATIVE
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(Report Continued from LIC 9099...)

On 07/29/2023, LPA Martha Arroyo conducted an initial 10-day complaint visit. During the visit, at 8:30 a.m., LPA conducted a physical plant tour to ensure there were no health and safety concerns. Between 8:04 a.m. and 10:03 a.m., the LPA conducted interviews with the administrator, one staff member, and three residents. At 8:55 a.m., the LPA conducted a resident file review and obtained copies of pertinent documents relevant to the investigation. LPA Arroyo also conducted one staff interview on 08/15/2023 at 3:13 p.m. and telephonic interviews with family members on 11/30/2023 at 10:13 a.m. and 10:55 a.m.

Investigator Bendana conducted interviews on 08/25/2023, at approximately 2:12 p.m., with R1’s resident representative; on 08/28/2023, at approximately 10:24 a.m., with the reporting party; on 09/12/2023, from approximately 11:02 a.m. to 11:35 a.m., with Staff #1 (S1), Staff #2 (S2) and residents; on 09/21/2023, at approximately 9:42 a.m., with the administrator; and at 10:28 a.m. attempted to interview R1, however, R1 declined to be interviewed. In addition, the investigator reviewed Adventist Health Simi Valley Hospital medical records and facility file documents related to R1.

A review of R1’s Physician Report, dated 06/13/2023, lists R1’s primary diagnosis as dementia. The secondary diagnosis is listed as osteoporosis, macular degeneration. The report noted R1 has a visual impairment, uses a walker and is a fall risk. The Preplacement Appraisal Information, dated 6/28/2023, indicates R1 is not able to walk without any physical assistance, is feeble or slow, uses a walker, is unsteady and needs assistance with all activities, even basic activities. R1 is at risk for falls, needs help transferring in and out of bed and dressing; needs help with bathing, hair care and personal hygiene; needs help with moving about the facility; needs assistance with toileting including equipment assistance or assistance of another person; and R1 needs special observation/night supervision due to confusion, forgetfulness and wandering.

A review of R1’s hospital medical records revealed R1 was admitted to Adventist Health Simi Valley Hospital on 07/22/2023, with the chief complaint of an unwitnessed fall, and left femur deformity. R1 was found to have a femur (hip) fracture and orthopedics were consulted. R1 had surgery to the left femoral shaft fracture intramedullary nailing. R1 was discharged to a Skilled Nursing Facility (SNF) on 07/27/2023 for rehabilitation. (Report Continued on LIC 9099C...)
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230728084857
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: RESIDENTIAL FIRST CARE, LLC
FACILITY NUMBER: 567609938
VISIT DATE: 01/19/2024
NARRATIVE
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(Report Continued from LIC 9099C...)

The investigation revealed the statements made by the overnight staff (S1) and the administrator were inconsistent. The administrator stated on 07/22/2023, S1 made rounds at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m.; however, staff interviews reflected that they could not recall how often rounds were made. Additionally, it was revealed that night rounds are done frequently but there is no set time for rounds. Moreover, interviews revealed that R1 fell at night and was found in the morning by S1. The administrator and S1 stated R1 used a bell to call for assistance, however, there was no evidence of a bell or call button found. Interviews conducted with other parties reflected that residents are checked on often during the day but not so much at night because caregivers slept and there was a lack of supervision at night. It was revealed that caregivers check on residents if it woke them up. R1’s resident representative was informed R1 was checked on between 3:00 a.m. and 4:00 a.m. Per the unusual incident/injury report (SIR) submitted to the department on 07/28/2023, S1 was starting their day at around 6:40 a.m., was checking on the residents and found R1 lying on the floor; no one heard or saw the fall. Interviews also reflected that R1 has a commode in R1’s room, which was noted to be wet. Due to the totality of circumstances, it is more likely than not that R1 sustained an unwitnessed fall while staff slept. Staff failed to provide care according to the preplacement appraisal.

The Department’s investigation provided sufficient evidence to substantiate that the facility staff slept and failed to supervise R1 resulting in an unwitnessed fall. Therefore, the allegation “Neglect/Lack of Supervision: Staff failed to supervise Resident #1 (R1) resulting in R1 sustaining a fracture from a fall while in care” is deemed Substantiated at this time.

(Report Continued from LIC 9099C...)
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230728084857
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: RESIDENTIAL FIRST CARE, LLC
FACILITY NUMBER: 567609938
VISIT DATE: 01/19/2024
NARRATIVE
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(Report Continued from LIC 9099C...)

It was also alleged that facility staff are not providing adequate supervision to residents in care and facility staff left resident in a soiled diaper for a long period of time. It was reported that facility staff is not providing proper supervision at night and that resident is often soiled when family arrives to the facility. During staff interviews, staff reported changing the residents at least every two (2) hours unless the resident requests to be changed before then. However, staff admitted to sleeping through the night and getting up to check on the residents only while they used the restroom themselves. Additionally, staff added that they check on the residents approximately two (2) times at night and at this time is when they see if the residents need anything. Interviews conducted with family members revealed that upon admission to the facility, they were informed that the facility felt residents required minimal supervision at night since they were sleeping and added that staff ‘did rounds here and there just to make sure they were okay’. Additionally, family stated the residents were clean in the evenings while they visited; however, they were unsure if the resident’s diapers were being changed during the night. Furthermore, nighttime supervision consist between 7 p.m. and 7 a.m. which is a twelve-hour span and staff were doing night checks approximately twice a night, indicating residents are not being provided adequate supervision and are being left in soiled diapers for a long period of time. Based on all the information obtained during the course of the investigation, the Department has sufficient evidence to support the allegations of “facility staff are not providing adequate supervision to residents in care” and” facility staff left resident in a soiled diaper for a long period of time”. Therefore, these allegations are being Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Administrator, Lidia Medina, 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 deficiency is cited (refer to LIC 9099-D)

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230728084857
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: RESIDENTIAL FIRST CARE, LLC
FACILITY NUMBER: 567609938
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2024
Section Cited
CCR
87464(d)
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87464(d) Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457...This requirement is not met as evidenced by:
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Licensee will submit plan how you will ensure residents will be supervised based on their individual needs. Submit to CCL by 01/22/2024.
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Based on interviews and records review, the licensee did not comply with the section cited above. Staff failed to supervise R1 resulting in R1 sustaining a hip fracture from a fall while in care, which posed an immediate health and safety risk to residents in care.
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An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)
Type B
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Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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The Licensee has agreed to review Regulation 87468.2 and submit a statement of understanding to CCL no later than 01/22/2024.
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Based on the investigation, the licensee did not comply with the section cited above, as residents are being checked approximately twice per night indicating residents are being left in soiled diapers for a long period of time, which poses a potential 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) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5