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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602669
Report Date: 12/03/2021
Date Signed: 12/03/2021 03:08:15 PM

Unsubstantiated


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
12/01/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211201135924
FACILITY NAME:LEISURE LIVINGFACILITY NUMBER:
197602669
ADMINISTRATOR:MICHELLE MAURERFACILITY TYPE:
740
ADDRESS:6156 HEDGEWALL DR.TELEPHONE:
(818) 879-9900
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 6DATE:
12/03/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Ross Hashemi, Licensee RepresentativeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident fell while in care.
Staff handled resident in rough manner.
Resident is not provided a bed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial complaint visit. The LPA met with Licensee Representatives Ross Hashemi and Pam Hashemi and explained the reason for the visit.

During today’s visit, the LPA spoke with staff at 8:45 a.m., 10:20 a.m., 10:34 a.m., and 11:00 a.m., interviewed Resident #1 (R1) and another resident at 9:00 a.m. and 1:35 p.m., interviewed a friend for R1 at 10:45 a.m., interviewed a responsible party for a resident whom resides here at 1:46 p.m., conducted a tour at 8:55 a.m., reviewed files at 11:30 a.m., and reviewed video evidence.

Regarding the allegation: Resident fell while in care
It was alleged that R1 fell, resulting in injury. Interviews and records review confirmed that R1 was admitted to this facility on 11/17/2021 as a result of a right femur fracture. Interviews with R1 confirmed that R1 wants to be independent and does not want to receive assistance from staff for ambulating throughout the facility, transferring, or using the restroom.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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-20211201135924
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: LEISURE LIVING
FACILITY NUMBER: 197602669
VISIT DATE: 12/03/2021
NARRATIVE
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Staff interviews and a review of facility documentation revealed that R1 oftentimes refuses assistance and when staff attempt to assist R1, R1 has become physically aggressive and verbally abusive. During today’s visit, the LPA witnessed R1 ask the staff for ‘privacy’ and to ‘not be bothered’ and R1 claimed to not need any type of assistance as they needed to get ‘stronger on their own’.

Interviews and records review confirmed that on 11/22/2021, R1 fell out of bed. R1 claimed that they felt themselves ‘sliding’ out the bed, so they used the half-rail for support as they slid out of bed. R1 rang a bell and staff assessed the situation and attempted to assist R1 up, yet R1 claimed that they did not want assistance. Staff then called the paramedics, yet R1 refused to go to the emergency room. The paramedics then assisted R1 back into bed. There were no apparent injuries at that time, and R1 denied being injured as a result of the fall. When asked why they do not ask for assistance, R1 claimed, “I do not need assistance.”

Based on the information, there is insufficient evidence to support the claim that due to lack of care and supervision, R1 suffered a fall, resulting in injury. The allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff handled resident in rough manner.


It is alleged that staff handled R1 in a rough manner, resulting in a bruise. Interviews, records review, and video surveillance confirmed that the evening of 11/29/2021, Staff #1 (S1) was cleaning in R1’s room. R1 appeared agitated and did not want S1 to clean the room. Interviews and video surveillance displayed that R1 attempted to hit S1 with a remote control as a result of increased agitation. Interviews revealed that later in the evening, S1 was attempting to assist another resident, R1 came out of their room and became agitated. S1 claimed that R1 was ambulating in their wheelchair when S1 attempted to assist R1 back into the room. S1 claimed that they tried to fix R1’s wheel and bent down to unlock R1’s wheelchair and alleged that R1 hit them across the face. As a result, S1 believed that R1 also hit their wrist on the railing in the hallway. S1, and other staff whom have provided care and assistance for R1, denied claims of retaliating, harming, or hitting R1. Whereas R1 also alleged that staff hit them on the head 2-3 times during NOC shift, staff denied all claims of hitting R1. Additional interviews denied claims of observing staff handing R1 or other residents in a rough manner. Staff interviews and a review of facility documentation revealed that R1 oftentimes refuses assistance and has been physically aggressive towards staff while receiving care.

Based on the information, there is insufficient evidence to support the claim that staff handled R1 in a rough manner. The allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20211201135924
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: LEISURE LIVING
FACILITY NUMBER: 197602669
VISIT DATE: 12/03/2021
NARRATIVE
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Regarding the allegation: Resident is not provided a bed.
It is alleged that R1 was told that sleeping in the bed was unsafe, and to sleep in an armchair. Interviews revealed that R1 did not like the physician prescribed hospital bed and felt that it was uncomfortable. Staff confirmed that they attempted to switch out the mattress and R1’s friend confirmed that they provided a thick blanket to make the bed more comfortable, but R1 did not like the bed. Staff stated that they continue to encourage R1 to sleep in their bed because it is for their safety, yet R1 refuses. The LPA toured R1’s room and observed the hospital bed with ½ rails. A review of R1’s documents confirmed that there was an order for the bed, with the accompanying ½ rails. R1 informed the LPA that they preferred to sleep in the armchair and did not think the bed was comfortable. During the visit, R1 demonstrated how they sleep in the armchair at night. Interviews confirmed that staff have relayed R1’s discomfort with the bed to R1’s primary care physician, yet an alternative solution has not been provided at this time.

Based on the information obtained, there is insufficient evidence to support the claim that R1 is not provided a bed. The 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: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
12/01/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211201135924

FACILITY NAME:LEISURE LIVINGFACILITY NUMBER:
197602669
ADMINISTRATOR:MICHELLE MAURERFACILITY TYPE:
740
ADDRESS:6156 HEDGEWALL DR.TELEPHONE:
(818) 879-9900
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 6DATE:
12/03/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Ross Hashemi, Licensee RepresentativeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident exposed to harmful chemicals
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial complaint visit. The LPA met with Licensee Representative Ross Hashemi and explained the reason for the visit.

During today’s visit, the LPA spoke with staff at 8:45 a.m., 10:20 a.m., 10:34 a.m., and 11:00 a.m., interviewed Resident #1 (R1) and another resident at 9:00 a.m. and 1:35 p.m., interviewed a friend for R1 at 10:45 a.m., interviewed a responsible party for a resident whom resides here at 1:46 p.m., conducted a tour at 8:55 a.m., reviewed files at 11:30 a.m., and reviewed video evidence.

Regarding the above allegation, it is alleged that staff mopped R1’s room while R1 was still in the room, which exposed R1 to harsh cleaning chemicals . Interviews, record review, and video surveillance confirmed that R1’s room required mopping, and S1 mopped R1’s room at approximately 9:30 p.m. on 11/29/2021. It was alleged that R1 asked S1 to stop mopping R1’s room, yet S1 was insistent that they had to do so at that time.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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 6
Control Number 29-AS-20211201135924
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: LEISURE LIVING
FACILITY NUMBER: 197602669
VISIT DATE: 12/03/2021
NARRATIVE
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R1 repeatedly asked S1 to stop, because they were being exposed to the strong cleaning smell. S1 claimed that they were doing what they were ‘instructed’ to do at that time and continued mopping R1's room. Interviews with R1 revealed that the chemical smell was strong, and felt that cleaning the room at that time was inappropriate when R1 asked S1 to stop.

Based on the information obtained, there is sufficient evidence to support the claim that despite requests to cease mopping, R1’s request was denied and R1 was exposed to harmful chemicals. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.

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

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20211201135924
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: LEISURE LIVING
FACILITY NUMBER: 197602669
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities. Residents ... shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
1. Submit a Statement of Understanding as to how the Personal Rights of all Residents will be maintained. Submit the Statement by 12/6/2021.
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Based on interview and video surveillance, the licensee did not comply with the section cited above, as R1’s requests were denied and R1 was exposed to harsh chemicals, which poses a potential health, safety and personal rights 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: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6