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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197601489
Report Date: 05/30/2024
Date Signed: 05/30/2024 02:11:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/04/2022 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20220404161032
FACILITY NAME:CARRIE'S BOARD AND CAREFACILITY NUMBER:
197601489
ADMINISTRATOR:CARRIE ACOSTAFACILITY TYPE:
740
ADDRESS:8430 COLBATH AVENUETELEPHONE:
(818) 893-7619
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 4DATE:
05/30/2024
UNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Carrie Acosta, Licensee TIME COMPLETED:
02:17 PM
ALLEGATION(S):
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Resident sustained pressure injuries due to neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 1:18 p.m., the LPA met with the Licensee and explained the reason for the visit.

During the initial visit on 4/12/2022, between 9:30 a.m. and 2:20 p.m., LPA Peraldi conducted a facility tour and reviewed records and obtained copies of pertinent documents. The LPA also conducted interviews with the Licensee, three (3) residents and two (2) staff. On 04/17/2022, the LPA conducted a file review of Resident #1 (R1’s) documents such as but not limited to, admission agreement, and medical records.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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-20220404161032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489
VISIT DATE: 05/30/2024
NARRATIVE
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Regarding the allegation: Resident sustained pressure injuries due to neglect. On 04/04/2022, the Department received a complaint alleging neglect as it was alleged that Resident #1 (R1) sustained pressure injuries while in care. During the initial visit, the Licensee did not mention R1 having pressure injuries. The Licensee stated that staff conduct body checks on all the residents to ensure there are no injuries or wounds. Per record review, R1 was admitted to the facility on 12/28/2021. R1 was admitted to Hospice of St. Clare on 12/28/2021. Per Hospice documents, R1’s primary diagnosis was listed as Cerebral infarction, unspecified and secondary Dx- Parkinson’s disease. Prior to R1 residing at the facility, R1 was hospitalized due to anocix injury to brain, fall, hx of stroke. At the time of being admitted to the facility, R1’s Hospital and hospice records do not indicate that R1 entered the facility with pressure injuries. R1’s hospice prognosis summary described R1 as bed bound with gastrostomy tube (g-tube) non-ambulatory, incontinent and increased needs in assistance with activities of daily living (ADLs). R1’s hospice prognosis summary also describes that hospice registered nurse (RN) educated facility staff on patient safety to avoid fails with safe transfers and on preventing skin break down. R1’s pressure injuries were first noted in a hospice communication log dated 03/01/2022 and noted the following: “Visiting LVN called and informing patient’s pressure ulcer on sacrococcyx area is not healing and is getting worst. MD notified and patient referred to Wound Masters for wound consult and treatment. Visiting LVN informed and to notify patient’s PCG. IDT made aware.” On 03/08/2022, Wound Master’s conducted an initial assessment for R1 and two (2) wounds were listed: Wound 1 location as Left Posterior Heel, Arterial Ulcer with fat layer exposed. Wound 2 location as Sacrococcygeal and listed as Pressure Ulcer Stage 3. On 04/04/2022, Wound Master’s summary of R1 noted three (3) new wounds, Left Upper Back (New Wound) Pressure Ulcer Stage 4. Right Hip (New Wound) Pressure Ulcer Stage 4. Left Heel Foot (Current Wound) Ulcer of skin with fat layer exposed. Right, Buttock (New Wound) Pressure Ulcer Stage 3. Sacrococcygeal, Sacral Region (Current Wound) Pressure Ulcer Stage 3. On 04/11/2022, Wound Master’s summary of R1 noted, a total of five wounds; Left Upper Back (New Wound) Pressure Ulcer Stage 4. Right Hip (New Wound) Pressure Ulcer Stage 4. Left Heel Foot (Current Wound) Ulcer of skin with fat layer exposed. Right, Buttock (New Wound) Pressure Ulcer Stage 4. Sacrococcygeal, Sacral Region (Current Wound) Pressure Ulcer Stage 4. R1 was soon hospitalized on 04/14/2024 and did not return to the facility. From the date of admission to the day that R1 was hospitalized, R1 sustained a total of five (5) wounds and Four (4) out of five (5) wounds listed were Stage 4. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220404161032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489
VISIT DATE: 05/30/2024
NARRATIVE
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Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). The Licensee/Administrator was informed that civil penalties might be assessed.

Exit interview conducted. A copy of the report and appeal rights was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20220404161032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a) (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Licensee agreed to submit a plan on how they will ensure that residents are provided with proper care and supervision to meet their individual health care needs. Submit to CCL by POC due date.
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Based on medical records, licensee did not comply with the section cited as staff did not provide the necessary care and supervision resulting in R1 sustaining pressure injuries while in care, 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/04/2022 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20220404161032

FACILITY NAME:CARRIE'S BOARD AND CAREFACILITY NUMBER:
197601489
ADMINISTRATOR:CARRIE ACOSTAFACILITY TYPE:
740
ADDRESS:8430 COLBATH AVENUETELEPHONE:
(818) 893-7619
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 4DATE:
05/30/2024
UNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Carrie Acosta, Licensee TIME COMPLETED:
02:17 PM
ALLEGATION(S):
1
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Resident sustained unexplained injury to arm
Facility is not allowing indoor visitation
Facility retaliating against resident
INVESTIGATION FINDINGS:
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3
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5
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7
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 1:18 p.m., the LPA met with the Licensee and explained the reason for the visit.

During the initial visit on 4/12/2022, between 9:30 a.m. and 2:20 p.m., LPA Peraldi conducted a facility tour and reviewed records and obtained copies of pertinent documents. The LPA also conducted interviews with the Licensee, three (3) residents and two (2) staff and a friend of Resident #1 (R1). On 04/17/2022, the LPA conducted a file review of Resident #1 (R1’s) documents such as but not limited to, admission agreement, and medical records.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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 6
Control Number 29-AS-20220404161032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489
VISIT DATE: 05/30/2024
NARRATIVE
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Regarding the allegation: Resident sustained unexplained injury to arm. On 04/04/2022, the Department received a complaint alleging Resident #1 (R1) sustained unexplained injury while in care. During the initial visit, the Licensee did not mention R1 having an arm injury. The Licensee stated that staff conduct body checks on all the residents to ensure there are no injuries. Per record review, R1 was admitted to the facility on 12/28/2021. R1 was admitted to Hospice of St. Clare on 12/28/2021. Per Hospice documents, R1’s primary diagnosis was listed as Cerebral infarction, unspecified and secondary Dx- Parkinson’s disease. Prior to R1 residing at the facility, R1 was hospitalized due to anocix injury to brain, fall, hx of stroke. R1’s hospital records dated 12/26/2021 from R1’s hospitalization prior to being admitted to the facility list but not limited to “Fracture of fifth metacarpal bone of right hand and Closed fracture of left elbow, initial encounter” as R1’s medical problems. R1’s hospice prognosis summary, plan of care, updated assessments and communication logs dated 12/28/2021 to 03/13/2022, did not indicate or document injuries to R1’s arm. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegations: Facility is not allowing indoor visitation. Facility retaliating against resident. On 04/04/2022, the Department received a complaint alleging that the facility was restricting family visits for Resident #1 (R1) due to facility retaliating against R1 from missed payments. During the initial visit, the Licensee stated that visitors are allowed inside the facility. The Licensee stated that the only time she limited visitation was during the COVID-19 pandemic or when the facility had COVID-19 outbreaks. The Licensee said that when there were COVID-19 outbreaks, visitors were able to visit the residents through windows. The Licensee confirmed that she has not received payments for R1 since January 2022 but stated that it did not matter if R1 was paying; the Licensee said that the facility still provides care and supervision. Interviews conducted with residents stated that they are allowed indoor visitation and no concerns were brought up about visitation. Interview with R1’s friend did not bring up concerns regarding indoor visitation. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6