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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609623
Report Date: 03/29/2022
Date Signed: 03/29/2022 05:33:57 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
07/10/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20200710140202
FACILITY NAME:INN AT THE PARK VENTURAFACILITY NUMBER:
197609623
ADMINISTRATOR:KURT NIEBRESFACILITY TYPE:
740
ADDRESS:21200 VENTURA BLVDTELEPHONE:
(818) 884-7100
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 119DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Rose AnguianoTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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9
Resident #1's fall was not reported to responsible party
Resident's change in condition was not reported to responsible party
Licensee did not comply with reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced at 9:35 a.m. to conduct a subsequent complaint visit. The LPA met with Administrator Rose Anguiano and explained the reason for the visit.

During the initial tele-visit conducted on 06/23/2020, LPA Brian Balisi spoke with Administrator Kurt Niebres at 11:58 a.m., requested documents, and conducted a virtual plant tour at 12:30 p.m. During today’s visit, the LPA conducted a tour with Administrator Rose Anguiano at 9:45 a.m., interviewed ten (10) staff members from 10:00 a.m. – 12:00 p.m., reviewed records, and interviewed thirteen (13) residents from 2:20 p.m. – 4:00 p.m.

ALLEGATION #1: Resident #1's fall was not reported to responsible party;
ALLEGATION #2: Resident's change in condition was not reported to responsible party
It was alleged that R1 suffered falls on approximately 6/15/2020 and 6/16/2020, yet this information was not shared with R1’s responsible party when the incidents took place. In addition, R1 had allegedly lost a substantial amount of weight and this had not been reported.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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 5
Control Number 29-AS-20200710140202
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: INN AT THE PARK VENTURA
FACILITY NUMBER: 197609623
VISIT DATE: 03/29/2022
NARRATIVE
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Information obtained with R1’s responsible party, credible witnesses, and facility Administrators whom worked at the facility at the time of the complaint submission revealed sufficient evidence that R1 had fallen on two occasions, yet it was not reported until R1’s responsible party went to the facility and inquired about R1’s condition. Administrators whom worked at the facility at the time of the complaint submission confirmed that the incidents should had been reported to the responsible party in a timely manner. During today’s visit, the LPA spoke with staff regarding this incident, yet staff were unable to provide sufficient detail regarding R1’s condition at the time of the complaint. In addition, there had been a change of facility management and the current Administrator admitted that there were limited documents and records left regarding R1. The LPA reviewed R1’s records that were retained during the initial visit on 7/20/2020, but the documents did not include any communication logs or notes that confirmed whether staff informed R1’s responsible party.

Based on the availability of evidence and staff confirmation, there is sufficient evidence to support the claim that R1’s change of condition and falls were not reported to the responsible party. These allegations are deemed Substantiated at this time.

Regarding the allegation: Licensee did not comply with reporting requirements


It was alleged that R1’s falls, hospitalizations, and change of condition were not documented and reported to the licensing department. The LPA reviewed incident reports submitted from the facility in 6/2020 and could not identify any incident reports submitted regarding R1’s hospitalization, falls or change of condition. In fact, the LPA identified that this facility did not submit any incident reports from January 2020 – mid-June 2020. During the visit conducted on 07/20/2020, LPA Chochian requested R1’s documents from the facility, including any communication notes pertaining to R1. However, records review did not reveal any internal facility documentation regarding a change of condition, or any submitted incident reports to the Department.

Based on the information obtained, there is sufficient evidence to support the claim that the facility did not fulfill reporting requirements. This allegation is deemed Substantiated at this time.


Pursuant to Title 22 of the CA Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report, and appeal rights, were provided via email.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200710140202
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: INN AT THE PARK VENTURA
FACILITY NUMBER: 197609623
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2022
Section Cited
CCR
87466
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87466 Observation of the Resident. When changes such as unusual weight gains... or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the ... resident's responsible person, if any.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:

Review Regulation 87466 and submit a Statement of Understanding, detailing how the facility will maintain compliance with Regulation 87466. Submit statement by 3/31/2022
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Based on the investigation, the license did not comply with the section cited above, as R1's responsible party was not notified of falls or a change of condition, which poses an immediate health and safety risk to residents in care.
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Type B
03/31/2022
Section Cited
CCR
87211(a)(1)(B)
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Reporting Requirements. Each licensee shall furnish to the licensing agency such reports ... but not limited to, the following: (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:

Review Regulation 87211 and submit a Statement of Understanding, detailing how the facility will maintain compliance with Regulation 87211. Submit statement by 3/31/2022.
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Based on the investigation, the licensee did not comply with the section cited above, as the licensee failed to submit incident reports, 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
07/10/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20200710140202

FACILITY NAME:INN AT THE PARK VENTURAFACILITY NUMBER:
197609623
ADMINISTRATOR:KURT NIEBRESFACILITY TYPE:
740
ADDRESS:21200 VENTURA BLVDTELEPHONE:
(818) 884-7100
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 119DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Rose AnguianoTIME COMPLETED:
05:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not safeguard resident's personal belongings and property
Licensee does not provide a safe environment for residents
INVESTIGATION FINDINGS:
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2
3
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5
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12
13
Licensing Program Analyst (LPA) Ashley Smith arrived unannounced at 9:35 a.m. to conduct a subsequent complaint visit. The LPA met with Administrator Rose Anguiano and explained the reason for the visit.

During the initial tele-visit conducted on 06/23/2020, LPA Brian Balisi spoke with Administrator Kurt Niebres at 11:58 a.m., requested documents, and conducted a virtual plant tour at 12:30 p.m. During today’s visit, the LPA conducted a tour with Administrator Rose Anguiano at 9:45 a.m., interviewed ten (10) staff members from 10:00 a.m. – 12:00 p.m., reviewed records, and interviewed thirteen (13) residents from 2:20 p.m. – 4:00 p.m.

Regarding the allegation: Licensee did not safeguard resident's personal belongings and property
It was alleged that on approximately 06/24/2020, R1’s clothing was missing and R1’s personal belongings had been rearranged in their room. Information obtained from staff interviews revealed insufficient evidence as to whether items were removed from R1’s room.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20200710140202
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: INN AT THE PARK VENTURA
FACILITY NUMBER: 197609623
VISIT DATE: 03/29/2022
NARRATIVE
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Per the information obtained, the other items in R1’s room were not removed, yet were rearranged for an unknown reason. Based on the information obtained at the time of the initial visit, it is unknown if R1’s clothes were removed to be washed, and/or if they were retrieved at a later date. The current staff and those who worked at this facility in June 2020 were unable to provide sufficient evidence pertaining to R1’s belongings. Per resident interviews, the majority of residents agreed they had not had anything missing from their rooms.

Based on the availability of evidence, there is insufficient evidence to support the claim that the licensee did not safeguard R1's personal belongings and property. This allegation is deemed Unsubstantiated at this time.


Regarding the allegation: Licensee does not provide a safe environment for residents
It was alleged that Resident #2 (R2) gets into altercations with staff and residents, and that staff do not respond appropriately. As of today, R2 still resides at this facility. However, most of the staff commented that R2’s behavior has improved, and believe it is due to the fact that Administrator Rose Anguiano makes it a point to speak to R2, creates appropriate boundaries with R2, and regularly reminds R2 as to how their behavior must align with facility policies and procedures. Per resident interviews, resident claimed that they feel comfortable residing this facility and believe that in general, staff are responsive if there are altercation and disturbances from residents. In regards to R2, residents claim that they know how to interact with the resident and do not feel unsafe, but feel comfortable communicating any concerns to the facility staff.

Prior administrators and staff were interviewed regarding altercations between residents (complaint# 20200929162632 and complaint #20200904163016), and staff claimed that staff were trained to intervene and separate residents as needed, and would respond to disputes in a timely manner. During today’s visit, staff claimed that whereas R2 may have outbursts, they do not feel unsafe working alongside R2. Whereas there have been incidents with the police being called or other escalating situation, staff and residents believe it was an appropriate response to a situation. The LPA reviewed incident reports pertaining to R2 and noted that whereas incidents occurred, staff appropriately intervened as needed.

Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that the licensee does not provide a safe environment for residents. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5