567610007-6-29-2023-29-AS-DPEA-CT9VSL-20230629164142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567610007
Report Date: 06/27/2023
Date Signed: 06/29/2023 04:33:34 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
08/31/2022 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20220831132941

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: 86	DATE:	06/27/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Margie Veis		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident is left soiled while in care
Staff not addressing a resident's incontinence needs
Staff did not properly monitor a resident's change in medical condition
Resident hygiene needs not met

INVESTIGATION FINDINGS:

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*This is report supersedes 9099 issued on 4/23/2023.
Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced subsequent complaint visit to deliver final investigation finding regarding above allegations. During today’s visit LPA met with Margie Veis, and explained the reason for visit.

On 08/31/2022 the Department received a complaint regarding the above allegations.

Following is a summary of the allegations and investigation findings:

Allegations: Resident is left soiled while in care and staff not addressing a resident’s incontinence needs. Information was reported that Resident #1 (R1) was observed in wet soiled clothing multiple times in 03/2022. It was also reported that staff did not assist R1 with toileting needs. During the initial visit on 09/08/2022, LPA conducted interviews with facility staff, and administrator at approximately 4:45 p.m.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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-20220831132941

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: 06/27/2023

NARRATIVE

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R1 was admitted to the facility on 01/31/2022. Facility observation log from 1/31/2022 – 6/2022 noted change in R1’s condition and service were provide accordingly. Staff interviewed reported that upon move in on 01/31/2022, R1 only needed verbal reminders with toileting, brushing teeth, bathing, and dressing. Staff reported noticing a decline in R1's condition from 02/2022 to 3/2022. According to staff R1's change in condition was always communicated to the responsible person. Facility observation notes from 02/2022 – 6/2022 and care plan dated 9/1/2022 revealed that R1 was easily agitated, combative at times and uncooperative. Staff reported that R1 would not cooperate with brushing and using water pick to clean teeth as the family requested.

A tour of the Memory care unit was conducted during the subsequent visit on 1/24/2023, with the Administrator from approximately 3:30 p.m. – 4 p.m. Random residents observed in the Memory Care unit appeared to be clean and dry. LPA made an attempt to interview five (5) residents in the Memory Care unit. Other potential witnesses interviewed during the course of investigation reported being satisfied with the care services.

Based on the information obtained through interviews and records review, there is not enough evidence to support allegations. Therefore, the allegations are deemed Unsubstantiated at this time.

Exit interview held, copy of report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220831132941

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: 06/27/2023

NARRATIVE

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Additional staff and resident interviews were conducted on 01/24/2023 from 2:30 p.m. - 3:15 p.m. Also, during the initial and subsequent visits facility records were reviewed. Records dated 10/21/2021, noted that R1 was confused/disoriented however, able to follow instructions; able to feed self and care for own toileting and hygiene needs. R1 was admitted to the facility on 01/31/2022. Facility observation log from 1/31/2022 – 6/2022, noted change in R1’s condition and increased/additional service provide. Staff interviewed reported that upon move in, R1 only needed verbal reminders with toileting, bathing, and dressing. Staff reported noticing a decline in R1's condition from 02/2022 to 3/2022. According to staff, R1's change in condition was always communicated to the responsible person. Staff reported that R1 was monitored daily at least every 2 hours for incontinent care needs. According to the staff no resident is purposely left in soiled clothing. Staff stated that incontinent care residents are checked in the mornings, before and after each mealtime, and at least every 2 hours day/night.

Allegation: Staff did not properly monitor a resident's change in medical condition. Information was received that R1 went to the hospital due to uncontrolled nosebleed on 4/3/2022. R1 returned from the hospital with nose plug to stay in for two (2) days. It’s alleged that staff did not follow through with monitoring R1 and as a result R1’s nose plugs were observed pulled out the next morning. Staff interviewed on 09/08/2022 and 01/31/2023 did not recall this incident. Staff reported that R1 was constantly agitated and at times combative. Staff reported that R1 was monitored night and day, every 2 hours. Facility observation notes dated 04/01/2022 noted that R1 was observed by staff in the hallway with apparent nosebleed; R1’s face was cleaned, and nose had stopped bleeding; R1 was monitored, and family was informed. There was no charting recorded for 4/2/2022 and 4/3/2022 for R1. On 4/4/2022 facility observation log noted: R1 was on monitoring for bloody nose; nose packed with gauze, minimal of blood noted; continued to monitor; 4/6/2022 charting indicates no blood in nostril; continue to monitor. No other charting regarding R1’s nosebleed was noted. According to staff, R1’s change in medical condition from move in was always communicated to R1’s physician and responsible person.

Allegation: Resident hygiene needs not met. Regarding this allegation there was concern that facility staff are not following through with brushing R1’s teeth and using a water pick. During the initial visit on 09/08/2022, LPA conducted interviews with facility staff, and administrator at approximately 4:45 p.m. Additional staff and resident interviews were conducted on 01/24/2023 from 2:30 p.m. - 3:15 p.m. Also, during the initial and subsequent visits facility records were reviewed. Records dated 10/21/2021, noted that R1 was confused/disoriented however able to follow instructions and care for own hygiene needs.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC9099 (FAS) - (06/04)

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