197606341-5-26-2022-31-AS-EMIR-CFWTZE-20220701151013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606341
Report Date: 05/26/2022
Date Signed: 05/26/2022 03:27:08 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2021 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20211005123059

FACILITY NAME:	LILY OF THE VALLEY		FACILITY NUMBER:	197606341
ADMINISTRATOR:	NATALIA L. ESPINO		FACILITY TYPE:	740
ADDRESS:	8618 BOTHWELL ROAD		TELEPHONE:	(818) 993-7800
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 4	DATE:	05/26/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rudolfo Espino		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained injury while in care resulting in death.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to close out the investigation regarding the above allegation.

Entrance interview conducted.
On 10-05-2021, a complaint was received by the Woodland Hills South Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s, Investigations Branch and investigated by Robert Kujawa.
The department initiated the 10 day visit 10/6/21. The LPA toured the home and reviewed documentation.

The investigator conducted interviews with staff on 2/14/22. Witnesses were interviewed on 3/14/22 and resident file reviews were conducted 08-18-2020. Medical documentation was subpoenaed 11/18/21, received and reviewed on 1/13/22.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

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 31-AS-20211005123059

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LILY OF THE VALLEY	FACILITY NUMBER: 197606341
	VISIT DATE: 05/26/2022

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

It was reported that on or around 9/24/21, Resident 1 (R1) was transported and admitted to the hospital with several bleeding wounds. No other specific details provided regarding how R1 obtained these wounds. R1 passed away on 9/27/21.

Interviews with the licensee, R1’s primary physician and R1’s family gave no indication that R1 sustained an injury, resulting in death due to facility neglect. Resident 2 (R2) was also interviewed and express no complaints or concerns regarding the care and supervision provided, stating satisfaction with facility services.

Review of medical records reveal that R1’s cause of death was due to pneumonia. R1 was taken to the hospital for shortness of breath with signs of fungal infection on the upper back that was treated by the doctor. A further review of the physician’s notes indicate that the doctor had been treating R1 for 20 years. R1 has had recurrent skin condition of the skin, chest wall and back. R1 had been under the doctor’s treatment for both antifungal and oval med diffusion.

Based on the information obtained through interviews and record review, there wasn’t enough evidence to corroborate the allegation of resident sustaining injury resulting in death. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2