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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850339
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:02:37 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
03/06/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240306081830
FACILITY NAME:INN AT THE PARK VENTURAFACILITY NUMBER:
195850339
ADMINISTRATOR:ANGUIANO, ROSEFACILITY TYPE:
740
ADDRESS:21200 VENTURA BLVDTELEPHONE:
(818) 884-7100
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 174DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rose AnguianoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision – Facility failed to seek timely medical attention when Resident #1 (R1) developed an illness (clostridium difficile colitis) while in care of the facility.

Staff did not communicate with resident's responsible party.

Facility failed to follow proper infection control guidelines.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Executive Director Rose Anguiano and explained the reason for the visit.

On 03/06/2024, the Department received a complaint report regarding a neglect/lack of supervision allegation. The complaint alleged that facility failed to seek medical attention in a timely manner when Resident #1 (R1) developed an illness while in care. In addition, the complaint alleged staff did not communicate with resident's responsible party (resident representative). The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Sonia Sandoval. The Department also conducted a Program Clinical Consultant (PCC) review of the information obtained during the investigation.
On 03/07/2024, from 10:30 a.m. to 2:45 p.m., LPA B. Balisi conducted an unannounced initial 10-day complaint visit. Upon arrival LPA Balisi met with Rose Anguiano, administrator, and explained the reason for the visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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 6
Control Number 29-AS-20240306081830
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: 195850339
VISIT DATE: 11/21/2024
NARRATIVE
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Continued from 9099
At approximately 10:30 a.m., the LPA toured the physical plant, interviewed staff, and reviewed and obtained pertinent documents relevant to the investigation. On 03/25/2024, at approximately 4:18 p.m., Investigator Sandoval conducted interviews with R1’s resident representative; on 04/16/2024, from approximately 12:00 p.m. to 2:45 p.m., with staff, administrator, and residents; on 06/17/2024, at approximately 2:54 p.m., with R1’s resident representative; and on 06/18/2024, from approximately 8:13 a.m. to 10:09 a.m., with Valley’s Best Hospice Registered Nurse, and R1’s telemedicine doctor. In addition, Investigator Sandoval reviewed Providence Tarzana Medical Center medical records, Southern California Hospital at Hollywood medical records, Los Angeles City Fire Department (LACFD) Emergency Medical Services (EMS) records, Valley’s Best Hospice medical records, County of Los Angeles Registrar-Recorder / County Clerk death certificate, and other facility file documents related to R1.

A review of R1’s facility file documents revealed that R1 was admitted to the facility on 06/09/2022. The Admissions Agreement’s basic services at minimum indicated continuous care and supervision, observation for changes in condition and notification to the resident’s family, physician, and other appropriate person/agency. The facility would assist with planning, arranging and or providing transportation to medical and dental appointments. Additional basic services that were checked off included “Assistance making and follow up on routine appointments…obtaining emergency care as needed.” The physician’s report dated 11/26/2023, listed R1’s primary diagnosis as dementia and secondary diagnoses were listed as hypertension, testicular cancer. The report documented bowel and bladder impairment, confused/disoriented, and wandering behavior. R1 was noted to be able to follow instructions and communicate needs. R1 was noted as being able to feed self but unable to leave the facility unassisted, unable to bathe, dress or groom. According to R1’s appraisal needs and services plan, updated on 12/06/2023, R1 was noted to have difficulties with physical development and poor health habits. R1 required assistance with all activities of daily living (ADLs) and potential for weight loss which required reminders to eat and drink fluids.

According to the Southern California Hospital at Hollywood medical records, on 01/21/2024, at approximately 5:41 p.m., R1 presented to the emergency department for abdominal pain. The records noted R1 had three (3) days of abdominal pain and diarrhea. The CT scan of abdominal and pelvis revealed diverticulosis with sigmoid diverticulitis. On 01/22/2024, at approximately 10:26 a.m., R1 was admitted to the hospital for IV antibiotics for a diagnosis which included acute rectosigmoid diverticulitis, significant leukocytosis, left lower quadrant abdominal pain, electrolyte imbalance with hypokalemia, dehydration, and dementia.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20240306081830
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: 195850339
VISIT DATE: 11/21/2024
NARRATIVE
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Continued from 9099-C
On 01/30/2024, the clinical update noted R1 tested positive for C. difficile colitis (C-diff). On 01/31/2024, R1 was discharged to the facility with a new medication of Vancomycin and a follow-up with primary care provided after two weeks. In addition, R1 was advised to go to the nearest emergency room if symptoms returned or worsened.

A review of the facility Medication Assistance Record (MARs) revealed no indication the new prescription for Vancomycin was administered as directed by the hospital. The interview with R1’s resident representative revealed the facility did not notify them of the hospital discharge instructions. R1’s resident representative was notified by staff that R1 had terrible diarrhea and R1 was going to be transported to Hollywood Hospital but was not transported until three to four days later 01/21/2024. R1’s resident representative stated they called daily for an update and the staff would tell them they were still waiting for R1 to be transported. R1’s resident representative indicated they told staff they were going to call 911 to have R1 transported and not until then was R1 transported to the hospital. In addition, due to the delay in medical attention in January 2024, R1’s resident representative stated when the facility informed them in February 2024 that R1 was having episodes of diarrhea again (recurrent), R1’s representative decided to have R1 assessed for hospice. The interviews with the facility staff revealed two staff stated the week prior to R1’s departure from the facility R1 was no longer observed in the common areas which was unusual for R1 and were informed by other staff that R1 was ill in R1’s room. There was no evidence found that the facility communicated with the staff regarding R1’s change of condition. Further, the facility did not provide staff training regarding how to care and monitor R1 with a contagious C-diff infection.

A review of the Valley’s Best Hospice records revealed R1 was on hospice for one day on 02/27/2024. The hospice assessment visit noted R1 was reportedly able to walk ten days prior and at the time of the assessment was bedbound, unable to stand on their own with episodes of diarrhea and no food intake for a few days. The interview of the hospice nurse revealed they were not expecting R1 to be in such bad condition and immediately contacted R1’s resident representative who was unaware of the change in condition.

A review of the medical records for the second hospitalization at Providence Tarzana Medical Center on 02/27/2024 revealed R1 was admitted to the hospital for dehydration and the final diagnosis included sepsis, unspecified severe protein-calorie malnutrition, and enterocolitis due to clostridium difficile (recurrent).
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20240306081830
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: 195850339
VISIT DATE: 11/21/2024
NARRATIVE
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Continued from 9099-C

R1 was prescribed Vancomycin for the C-diff however was unable to pass a swallow test. Therefore, the Vancomycin was held given R1’s aspiration risk. Palliative care and code status were discussed with R1’s resident representative who elected comfort care measures only and R1 passed away on 02/29/2024.

The interview of R1’s telemedicine doctor revealed the facility never notified them of a change in condition in R1 and stated if R1 had been medically assessed in a timely manner, the recurrent C-diff condition may have been resolved. The review of the death certificate revealed septic shock, gastrointestinal bleeding and C-diff listed as conditions leading to the cause of death.

The Department conducted a Program Clinical Consultant (PCC) review of the information obtained during the investigation. Based on the review of the medical records, the Departments’ investigative findings, and other miscellaneous documents, the PCC review determined the facility failed to provide proper care and supervision that resulted in R1’s death from Septic shock and the recurrence of C-diff. Based on the information gathered during the investigation, the facility failed to seek timely medical attention for R1 who developed a recurrent illness while in care, failed to notify R1’s resident representative or physician with R1’s change of condition, and failed to train the staff on R1’s contagious C-diff infection. Therefore, the allegations “Neglect/Lack of Care and Supervision – Facility failed to seek timely medical attention when Resident #1 (R1) developed an illness (clostridium difficile colitis) while in care of the facility” and “Staff did not communicate with resident's responsible party” and “Facility failed to follow proper infection control guidelines” are deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Executive Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20240306081830
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: 195850339
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2024
Section Cited
CCR
87465(g)
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(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…
This requirement is not met as evidenced by:
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Licensee agreed to submit a plan how you will ensure residents receive timely medical care. Submit to CCL by due date.
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Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff did not seek timely medical care when R1 had C-diff and recurring symptoms, which posed an immediate health and safety risk to residents in care.
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Type A
11/22/2024
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes…or a physical health condition are observed, the licensee shall ensure... resident's physician and the resident's responsible person…This requirement is not met as evidenced by:
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Licensee agreed to submit a plan how you will ensure residents responsible party and physician are notified of changes in condition. Submit to CCL by due date
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Based on interviews, the licensee did not comply with the section cited above. Facility staff did not notify R1’s representative or physician when R1 had a change in physical health condition, which posed an immediate 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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20240306081830
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: 195850339
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2024
Section Cited
CCR
87470(b)(2)(C)
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(b) In addition to subsection (a), when one or more residents…. Are diagnosed with a contagious disease, the following shall apply:...are trained in the proper use of all required PPE... quarantine or isolation, from others.This requirement is not met as evidenced by:
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Licensee agreed to submit a plan how you will ensure staff receive training on infection control as necessary and annually. Submit to CCL by due date
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Based on record review, the licensee did not comply with the section cited above. The facility failed to provide the staff training regarding how to care and monitor the resident with a C-diff infection, which posed an immediate 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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6