197601489-1-14-2025-29-AS-KLOZ-DDCVKE-20250128153012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197601489
Report Date: 01/14/2025
Date Signed: 01/14/2025 05:50:31 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
01/02/2025 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20250102084848

FACILITY NAME:	CARRIE'S BOARD AND CARE		FACILITY NUMBER:	197601489
ADMINISTRATOR:	CARRIE ACOSTA		FACILITY TYPE:	740
ADDRESS:	8430 COLBATH AVENUE		TELEPHONE:	(818) 893-7619
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 3	DATE:	01/14/2025
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Carrie Acosta		TIME COMPLETED:	02:28 PM

ALLEGATION(S):

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Staff did not ensure medical attention was provided to resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the allegation listed above. The LPA met with the Licensee Carrie Acosta and explained the reason for the visit.

On 01/07/2025, LPA Urena conducted the initial 10-day visit, interviewed the staff and the administrator, and requested records pertinent to the investigation. Further investigation is needed at this time.

Continues on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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-20250102084848

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: 01/14/2025

NARRATIVE

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Staff did not ensure medical attention was provided to resident in a timely manner.
On the allegation that the staff did not ensure medical attention was provided to resident in a timely manner; it is the concern of the reporting party (RP) that R1 sustained an un-witnessed fall, and after the staff (S1) discovered R1 on the floor, S1 failed to provide immediate assistance to R1 and did not call 911 until five (5) hours after R1 was discovered on the floor. The interview with S1 revealed that after S1 discovered R1 on the floor, S1 attempted to assist R1 to get up, but R1 did not want to be touched, and mumbled something. S1 did not notice any injuries, and R1 was not complaining of pain. Furthermore, S1 stated that they called R1’s POA before calling 911 and asked the POA if they wanted S1 to wait on calling 911 until the POA arrived at the facility, and the POA stated, “Yes”. The interview with the administrator revealed that after being informed by S1 that R1 had sustained a fall, they told S1 that they should have called 911 to provide medical assistance to R1 right away, then S1 should have called the POA and the administrator. The LPA interviewed the POA on 01/07/2025, and the interview revealed that on 12/27/2024, the POA received a call from the facility and was informed at approximately 10:00 a.m. of the fall sustained by R1. The POA stated that after S1 explained the incident, S1 asked the POA if S1 should wait until the POA arrived before calling 911, and the POA stated, “yes to wait”. The POA arrived at the facility and saw R1 laying on the floor. The POA noticed bruising on the left side of the forehead, shoulder and wrist. Emergency medical team (EMT) personnel arrived at the facility and found R1 lying face down on the ground. When asked what happened, R1 stated that they slid out of bed, onto the floor earlier in the morning, and R1 reported bilateral leg pain. EMT noticed that R1 had visible bruising to the left shoulder and mild swelling to the left side of the face.

Based on the information received through interviews, the facility staff did not ensure medical attention was provided to R1 in a timely manner. S1 waited approximately four (4) hours, before calling 911, and getting medical assistance to R1. Therefore, the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency was cited (refer to LIC 9099-D).

Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250102084848

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: 01/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/24/2025 Section Cited CCR 87468.1(b)(8)	1 2 3 4 5 6 7	87468.1 (b)(8)-Deny or restrict medical or nonmedical care that is appropriate to a resident’s organs and bodily needs or provide medical or nonmedical care to the resident in a manner that, to a similarly situated reasonable person, unduly demeans the resident’s dignity or causes avoidable discomfort. This requirement was no met as evidenced by:	1 2 3 4 5 6 7	Licensee or a qualified instructor will provide training to staff on providing immeadite care to residents in facility. Licensee will email a sign in sheet and copies of the materials used for the training by 01/24/2025.
	8 9 10 11 12 13 14	Based on interviews the licensee did not comply with the above regulation as R1 sustained a fall, with visible bruises to the left side (forehead, wrist and knee) and pain in knee, and timely medical attention was not provided which poses a potential personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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