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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608325
Report Date: 07/22/2021
Date Signed: 07/22/2021 01:32:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2019 and conducted by Evaluator Martha Guzman-Chavez
COMPLAINT CONTROL NUMBER: 31-AS-20190723103029
FACILITY NAME:ZANN DAILY CAREFACILITY NUMBER:
197608325
ADMINISTRATOR:ANN SOLAKYANFACILITY TYPE:
740
ADDRESS:11500 BAIRD AVENUETELEPHONE:
(818) 635-9471
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY:6CENSUS: 5DATE:
07/22/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ana SolakyanTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff neglect resulted in Resident #1 (R1) sustaining multiple pressure injuries – SUBSTANTIATED
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced subsequent complaint visit to the above facility. The purpose of the visit is to conclude an investigation initiated by LPA D. Perera on 07/24/2019. Upon arrival, LPA met with Administrator Ana Solakyan. Entrance interview conducted and the reason for the visit was explained.

On 07/24/2019, LPA Perera conducted an initial 10-day visit, at which time copies of pertinent documents from Resident #1 (R1) facility file was obtained and reviewed. On 07/24/2019 at 8:55am, LPA conducted a tour of the physical plant and interviews were conducted with administrator and staff at 9:10am. During the course of the investigation, LPA also obtained medical records pertaining to R1 from Northridge Hospital Medical Center and Top Choice Home Health. On 07/23/2019, LPA conducted an interview with the responsible party of R1.

Continued on LIC 9099c
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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 4
Control Number 31-AS-20190723103029
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ZANN DAILY CARE
FACILITY NUMBER: 197608325
VISIT DATE: 07/22/2021
NARRATIVE
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Continued from LIC 9099

On 09/12/2019 and 09/16/2019, LPA conducted interviews with various personnel, including but not limited to Wound Specialist, Emergency Room (ER) nurse, and Social Worker from Northridge Hospital Medical Center. Additionally, on 09/11/2019 and 09/19/2019, interviews were conducted with various Top Choice Home Health personnel, including but not limited to Director of Nursing, Nurse Practitioner (NP) and Registered Nurse (RN). On 11/04/2019, LPA also conducted an interview with West Coast Wound and Skin personnel. Medical records were reviewed by LPA on 08/26/2019, 09/09/2019 and 09/10/2019. This case was referred to the Community Care Licensing Divisions (CCLDs) Program Clinical Consultant (PCC) for further review.

It was alleged that facility staff neglect resulted in R1 sustaining multiple pressure injuries. Information gathered and reviewed revealed that R1 was admitted to the facility on 06/18/2019. On 06/21/2019, R1 was evaluated by a Nurse Practitioner (NP) who assessed that R1 had a possible recurrent urinary tract infection (UTI), dementia, gait abnormality, was wheelchair bound and had Stage 2 pressure ulcers at left hip, right hip, right ankle along with other comorbidities. Home Health (HH) was ordered for assistance with Activities of Daily Living (ADLs) and wound management. On 06/24/2019, a Registered Nurse (RN) from HH conducted a nursing assessment and wound care to R1. Documents reflected R1 had a stage 2 pressure injury to the left hip only. Per physicians’ orders, R1 was provided wound care by HH from 06/25/2019 to 06/30/2019. However, HH documents did not reflect other pressure injuries on right hip and ankle.

R1 was transferred to Northridge Hospital due to generalized weakness, shortness of breath and cough on 06/30/2019. Per hospital records, R1 was admitted to the hospital for Sepsis and acute respiratory failure. Furthermore, the nursing assessment from the hospital indicated multiple pressure injuries as follows: bilateral hips (stage 2), right ischium (stage 1), left shoulder (stage 1), bilateral ankles (stage 1), left lateral foot (stage 1), right heel/right medial foot (stage 1), right knee (stage 2) and right buttock. On 07/08/2019, the hospital wound care consultation was conducted. Per hospital records, the family of R1 did not want R1 discharged to a skilled nursing facility (SNF). Therefore, wound care treatment was ordered and R1 was discharged back to the facility on 07/08/2019.

Continued on LIC 9099c

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20190723103029
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ZANN DAILY CARE
FACILITY NUMBER: 197608325
VISIT DATE: 07/22/2021
NARRATIVE
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Continued from LIC 9099c

HH resumed its services for R1 on 7/9/2019. Per nursing assessment, the following injuries were noted: Right ankle (stage 2), left hip (stage 2), right hip (stage 2), right knee (stage 2), and right lateral foot (stage 1). R1 received wound care from HH on 07/09/2019, 07/11/2019 and 07/13/2019. Per HH records, HH nurses reported a new stage 2 pressure injury on the coccyx on 07/13/2019. R1 was further evaluated by a wound care clinic on 07/16/2019, which documented as follows: left hip acute stage 2 pressure injury; coccyx, acute full thickness skin tear; right hip, acute partial thickness skin tear; right knee, acute full thickness skin tear and right ankle, acute deep tissue pressure injury.

Information gathered revealed on 07/19/2019, R1 had a change in condition including extreme weakness and lethargy. On 07/09/2019, R1 was visited at the facility by the NP due to R1’s change in condition. Per interviews, the NP was aware of R1s pressure injuries to the left hip however, facility staff did not inform NP of the additional pressure injuries. Per the NPs expert opinion, all signs directed towards a possible wound infection therefore, Emergency Medical Services (EMS) were contacted and R1 was transported to Northridge Hospital at approximately 7:40pm. On 07/20/2019, at approximately 1:00am, R1s wounds were assessed and R1 was reported to have an unstageable pressure injury on the left 2nd toe, stage 2 on the right knee, stage 2 on the left inner thigh, unstageable on right lower shin, unstageable on left upper shin, stage 2 on right lateral buttock, stage 2 on coccyx, deep tissue injury on right malleolus, two (2) deep tissue injury right lateral foot, stage 1 on right achilles and unstageable on left hip. Interviews with facility staff revealed that they would put ointment on R1s wounds, if needed and would reposition every hour or two. However, based on expert opinion, it was revealed that R1s wounds on the hips significantly worsened and was possibly due to R1 not being repositioned for extended periods of time. Based on all information gathered during the course of the investigation, the above allegation, “Facility staff neglect resulted in Resident #1 (R1) sustaining multiple pressure injuries” is deemed SUBSTANTIATED at this time.

A $500 immediate civil penalty is assessed today. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).


Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report has been issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20190723103029
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ZANN DAILY CARE
FACILITY NUMBER: 197608325
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2021
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are…qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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The Administrator has agreed to submit a Statement of Understanding, explaining the steps the facility will follow to avoid similar issues from happening again and to ensure compliance to Title 22 Regulations regarding emergency medical assistance on or before 7/23/2021.
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Based on interviews and records review, licensee did not comply with the above the section by not providing the appropriate care, supervision, and competent staffing to R1 which resulted in R1 sustaining multiple pressure injuries.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4