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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850339
Report Date: 12/20/2024
Date Signed: 12/20/2024 12:15:00 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
11/17/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20231117153705
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: 173DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rose AnguianoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident sustained falls resulting in injury due to lack of staff supervision while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegation listed above. During today’s visit, LPA met with Executive Director Rose Anguiano and explained the reason for the visit.

On 11/20/2023, the initial complaint visit was conducted by LPA between approximately 10:30 a.m. - 12:30 p.m. During the visit, LPA conducted a tour of the physical plant, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 01/11/2024, between 10:30 a.m. – 03:30 p.m., LPA conducted interviews with twelve (12) residents while on site for a complaint visit on a separate investigation. On 12/18/2024, LPA reviewed medical records from Skirball Hospice.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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 7
Control Number 29-AS-20231117153705
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: 12/20/2024
NARRATIVE
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Continued from 9099

It was reported that "Resident sustained falls resulting in injury due to lack of staff supervision while in care" as it was alleged that Resident #1 (R1) sustained multiple falls due to lack of staff supervision. A review of facility records shows that Resident #1 (R1) was admitted to the facility on 01/02/2020 and began receiving hospice services from Skirball Hospice on 08/25/2023. A Level of Care assessment dated 08/26/2023, and an Appraisal/Needs and Services Plan dated 08/24/2023, indicate that R1 is ambulatory and does not use assistive walking devices. However, R1 is at risk of falling due to poor balance and has no safety awareness or ability to follow safety instructions. R1 requires supervision and standby assistance. A review of Skirball Hospice records, covering six visits between 10/09/2023, and 11/10/2023 confirms that R1 is a high fall risk due to poor safety judgment and an unsteady gait, and can only walk with assistance or supervision.

Interviews and record review indicated that on 11/14/2023, at approximately 9:30 a.m., R1 was in the dining room, attempted to get up from a chair, lost their balance, and fell. Staff #1 (S1) approached R1 to ensure their comfort and contacted Staff# 2 (S2), who assessed R1 on the floor and called 911. Emergency Medical Services (EMS) arrived approximately 10 minutes later and transported R1 to a local hospital. R1 returned to the facility at 09:30 p.m. On 11/15/2023, R1 was visited by Skirball Hospice RN and the following was observed: “(2) stitches on left brow, Bruise present over left eye / brow. No dressing needed at this time. No other injuries reported. No nonverbal s/s of pain, discomfort, or respiratory distress noted. All needs are met”. On 11/16/2023, at approximately 6:30 p.m., R1 was again in the dining room, stood up from a chair, took a few steps, and tripped on a chair. Caregivers attempted to prevent the fall but were unsuccessful. As a result, R1 sustained an open wound on their head. Staff #3 (S3) was contacted and assessed R1 in the dining room, provided first aid, called 911, and R1 was transported to a local hospital. On 11/17/2023, R1 returned to the community. Skirball Hospice RN conducted a visit and notated that there were no signs of pain or any distress. Facility records reviewed did not reflect that the facility completed or conducted a reappraisal or updated the residents needs and services after the falls to ensure the R1s needs were met.


Continued on 9099-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20231117153705
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: 12/20/2024
NARRATIVE
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Continued form 9099-C

Based on information gathered during the investigation the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation "Resident sustained falls resulting in injury due to lack of staff supervision while in care" has been 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: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20231117153705
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: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2024
Section Cited
CCR
87468.2(a)(4)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents...(4) To care, supervision...sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Licensee will submit a plan on how they will ensure staff will monitor and supervise residents in a timely manner. Licensee will provide plan to LPA via email by COB 12/23/2024
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Based on interviews and records review, the licensee did not comply with the section cite above as facility staff did not properly supervise R1 as per their care plan, 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: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
11/17/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20231117153705

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: DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rose AnguianoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not provide assistance to resident as needed while in care.

Facility is odiferous.

Staff did not ensure resident’s toileting needs were met while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegations listed above. During today’s visit, LPA met with Executive Director Rose Anguiano and explained the reason for the visit.

On 11/20/2023, the initial complaint visit was conducted by LPA between approximately 10:30 a.m. - 12:30 p.m. During the visit, LPA conducted a tour of the physical plant, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 01/11/2024, between 10:30 a.m. – 03:30 p.m., LPA conducted interviews with twelve (12) residents while on site for a complaint visit on a separate investigation. On 12/18/2024, LPA reviewed medical records from Skirball Hospice.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20231117153705
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: 12/20/2024
NARRATIVE
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Continued from 9099-A
It was reported that "Staff did not provide assistance to resident as needed while in care" as it was alleged that on 11/16/2023, when Emergency Medical Services (EMS) arrived on site to attend to R1, that R1 was found on the floor and staff did not make any attempts to assist R1 or clean up blood. Interviews and record reviews revealed that Staff #3 (S3) provided immediate first aid to Resident 1 (R1) by applying gauze to the head injury and ensuring R1 was in a stable and comfortable position until Emergency Medical Services (EMS) arrived. S3 confirmed that there was blood on the floor, but the dining room was cleared, and no one was at risk of slipping. After R1 was transported by EMS, the blood was promptly cleaned up. 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 did not provide assistance to resident as need while in care” is deemed Unsubstantiated at this time.

It was reported that "Facility is odiferous" as it was alleged that the facility had a strong smell of marijuana. LPAs interview with twelve (12) residents revealed that nine (9) residents have not detected the smell of marijuana inside the facility. The remaining three (3) residents reported having smelled marijuana in the halls at some point, but they are unsure if anyone is smoking inside the facility or if the smell came from marijuana smoked outside the facility. These three (3) residents could not recall the specific time or date when they noticed the smell. In addition, interviews with six (6) staff members, all confirmed that smoking is not permitted in resident rooms, and none have ever smelled marijuana in the common areas due to a resident smoking. However, all (6) staff members acknowledged that some residents smoke marijuana and may return to the facility with the smell of marijuana on their clothing. Staff reminded residents to be mindful of the scent to avoid disturbing others. During a walk-through of the facility, the LPA did not observe any marijuana use or detect the smell of marijuana. 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 “Facility is odiferous” is deemed Unsubstantiated at this time.

It was reported that "Staff did not ensure resident's toileting needs were met while in care" as it was alleged that when R1 was being observed by emergency personnel during the fall that occurred on 11/16/2023, they observed R1 had soiled themselves and there was a strong odor of urine and feces.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20231117153705
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: 12/20/2024
NARRATIVE
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Continued from 9099-C

Interviews conducted revealed that before the fall around 6:30 p.m., R1 did not appear visibly soiled or have a strong odor of urine or feces. Residents are typically checked for incontinence every three (3) hours and before meals. If R1 had been visibly soiled before being brought to the dining room, staff would have provided incontinence care. Additionally, during interviews with S3 and S4, they stated they do not remember if R1 was visibly soiled or had an odor of urine or feces after the fall. 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 did not ensure resident's toileting needs were met while in care” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7