<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603437
Report Date: 11/18/2022
Date Signed: 11/18/2022 02:53:51 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
11/14/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20221114152952
FACILITY NAME:LEISURE LIVING INC.FACILITY NUMBER:
197603437
ADMINISTRATOR:PARVIN HASHEMIFACILITY TYPE:
740
ADDRESS:30821 CATARINA DR.TELEPHONE:
(818) 879-9988
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 6DATE:
11/18/2022
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Pam HashemiTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained an unexplained injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct an initial complaint visit. The LPA met with staff Pam Hashemi and explained the reason for the visit.

Today, the LPA obtained documents, interviewed Resident #1’s responsible party at 12:35 p.m., and interviewed staff at 12:10 p.m., 12:20 p.m., and 12:50 p.m.

Regarding the allegation, it was alleged that Resident #1 (R1) suffered a laceration between two fingers, yet there were questions as to how R1 sustained the injury. The LPA interviewed staff whom were with R1 when R1 sustained the cut. On 11/10/2022 at approximately 3:45 p.m., Staff #1 (S1) was assisting R1 with a diaper change. Staff claimed that when S1 attempted to put the diaper on R1, R1 grabbed the diaper, and in the process, R1’s fingers went in between the diaper and suffered somewhat of a paper cut. S1 said that R1 had attempted to take the diaper off, which is when R1 sustained an injury. S1 said that the diaper then fell to the floor, and upon looking at it, S1 observed that there was blood on the diaper.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
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 2
Control Number 29-AS-20221114152952
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 INC.
FACILITY NUMBER: 197603437
VISIT DATE: 11/18/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
S1 then checked R1 to identify the source of the bleeding, and observed that R1 suffered a laceration between their ring finger and pinky finger on the right hand. Staff then requested assistance from Staff #2 (S2), whom then assisted S1 with providing first aid to R1’s cut.

Staff called R1’s home health agency and informed them of R1's injury. Home health arrived shortly after, and claimed that R1's cut required stitches, which the home health representative was unable to provide such medical treatment. As such, 9-1-1 was called and R1 was sent to the hospital on 11/10/2022 at approximately 6:20 p.m. R1 returned to facility on 11/11/2022 early in the morning, with stitches to the right hand.

During today’s visit, S1 took the LPA into the bathroom where the incident took place. S1 denied claims that R1 was in reach of any sharp objects during the diaper change other than the diaper itself. Staff confirmed that after R1 sustained the cut, staff called R1’s responsible party and the Licensee to inform them of the incident. The LPA spoke with R1’s responsible party, whom confirmed that they were notified after R1 sustained the cut and corroborated claims that they were informed that it happened while R1 was being changed. R1’s responsible party noted that as R1 takes a blood thinner, R1 was at risk for excessive bleeding. R1’s responsible party also reported that R1 had a history of agitation while receiving assistance with diaper changes. The LPA reviewed R1's Physician's Report dated 9/14/2022, where it was indicated that R1 exhibited aggressive behavior.

Licensee Ross Hashemi called the LPA on 11/16/2022 to ensure that the LPA received the Unusual Incident Report that was sent from the facility. Records review confirmed that the facility sent in an Incident Report regarding this incident on 11/11/2022.

Based on the information obtained in interviews and record review, there is insufficient evidence to support the claim that R1 suffered an unexplained injury. This 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: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2