567610007-6-28-2024-29-AS-DPEA-D6P5SZ-20240628201335

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567610007
Report Date: 06/28/2024
Date Signed: 06/28/2024 01:55:14 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
06/04/2024 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20240604133653

FACILITY NAME:	VARENITA OF SIMI VALLEY		FACILITY NUMBER:	567610007
ADMINISTRATOR:	VEIS, MARGIE		FACILITY TYPE:	740
ADDRESS:	3921 COCHRAN STREET		TELEPHONE:	(805) 327-1100
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	110	CENSUS: 100	DATE:	06/28/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Margie Veis		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff are not following physician's orders for the resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. Upon arrival LPA met with Executive Director Margie Veis and explained the reason for the visit.

During the initial visit on 6/11/2024, between 1:50 p.m. and 4:00 p.m. LPA conducted physical plant, interviewed staff, resident and reviewed obtained pertinent documentation relevant to the investigation. Today LPA interviewed staff and reviewed and obtained additional documentation relevant to the investigation.

It was reported that "Staff are not following physician's orders for the resident" as it was alleged that staff are not using a waist belt on Resident #1 (R1)'s wheelchair as prescribed. Interviews conducted and records review reflected on 04/13/2024 at approx. 5pm, R1 sustained a fall in their apartment , which resulted in R1 getting admitted into a local hospital.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

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-20240604133653

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: VARENITA OF SIMI VALLEY	FACILITY NUMBER: 567610007
	VISIT DATE: 06/28/2024

NARRATIVE

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Continued from 9099

On 05/02/2024, R1 was discharged from the hospital into a Skilled Nursing Facility. On 05/09/2024, R1 returned to the facility. On 05/21/2024, R1's POA obtained a physician's order to "use a waist belt restraint as needed to prevent falling out of chair" , from a physician at the Skilled Nursing Facility. Facility did not use a waist belt as it was not compliant with Title 22. In addition, R1' s Primary Care Physician did not provide a physician's order to make use of waist belt at this facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff are not following physician's orders for the resident” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

LIC9099 (FAS) - (06/04)

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