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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609055
Report Date: 06/13/2022
Date Signed: 06/13/2022 04:14:24 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, 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
06/10/2022 and conducted by Evaluator Wendell Smith
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220610145602
FACILITY NAME:SK MARATHON HOME CAREFACILITY NUMBER:
197609055
ADMINISTRATOR:KIM, SUN ILFACILITY TYPE:
740
ADDRESS:7246 FALLBROOK AVETELEPHONE:
(818) 912-6757
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 3DATE:
06/13/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sarah Kim, Sunk KimTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility is unsanitary.
Facility is not following Covid-19 screening protocols.
Facility appliances are in disrepair
Resident(s) have access to harmful chemicals while in care.
Doorknobs are obstructed to keep residents from moving freely throughout facility and leaving the facility
Ombudsman Poster is not visible to residents at the facility.
Facility has bugs
Facility staff is not allowing residents to speak with visitors privately
Residents are not being provided activities while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA met with the administrator and explained the reason for this visit.
LPA conducted a physical plant tour of the facility from approximately 10-10:40am to ensure no immediate health and safety issues were present. Regarding the allegations above LPA went over the allegations with the administrator.

Facility is unsanitary
It is alleged that the facility is dirty and unkempt in some areas of the facility. During the physical plant walk through LPA did observed there clutter and debris in some areas of the facility. In the bathroom LPA observed a pair of dirty shoes in the bathtub. LPA also observed spider webs in the corner of some areas in the facility. Based on information obtained through observation this allegation is deemed Substantiated at this time.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
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 7
Control Number 31-AS-20220610145602
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: SK MARATHON HOME CARE
FACILITY NUMBER: 197609055
VISIT DATE: 06/13/2022
NARRATIVE
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Facility is not following Covid-19 screening protocols.
It is alleged that facility staff are not screening visitors for Covid-19 symptoms by taking visitor's temperatures and that facility staff is not wearing mask around the facility. Upon entry to the facility, facility staff did not take LPA's temperature and staff were observed to not be wearing mask during the initial part of the visit. After approximately five minutes into the visit staff put their mask on. Based on the information obtained through observation this allegation is deemed Substantiated.

Facility appliances are in disrepair
It is alleged that during a visit by a verified witness on 5/6/22 that the facilities dryer and the toilet in the resident bathroom to not be working properly. It was also noted that there were several cords on the ground throughout the facility that were a tripping hazard for the residents. LPA spoke with facility staff regarding this allegation. Administrator stated that the toilet and dryer have been fixed since 5/6/22. LPA observed facility staff pick up cords that were laying on the ground around the facility. Based on the information obtained through interview and observation this allegation is deemed Substantiated.

Resident(s) have access to harmful chemicals while in care.
It is alleged that facility has cleaning supplies that are not locked up and are accessible to residents. During the physical plant walk through LPA observed cleaning supplies accessible to residents and not locked away. Based on the information obtained through observation this allegation is deemed Substantiated at this time.

Doorknobs are obstructed to keep residents from moving freely throughout facility and leaving the facility.
It is alleged that facility has a device on the doorknobs entering the facility and in some resident bedrooms which stop residents from opening the doors. During the physical plant walk through LPA observed a device on the door to stop residents from opening the door. LPA also observed a device on a resident's door which stopped them from opening the door. LPA spoke with the administrator about this allegation and was told that they had it on there to stop residents from wandering in the middle of the night. Based on the information obtained through interviews and observation this allegation is deemed Substantiated at this time.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 31-AS-20220610145602
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: SK MARATHON HOME CARE
FACILITY NUMBER: 197609055
VISIT DATE: 06/13/2022
NARRATIVE
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Ombudsman Poster is not visible to residents at the facility.
It is alleged that the facility did not have an Ombudsman poster visible to the residents in the facility. LPA spoke with the administrator regarding this allegation. Administrator stated that they did not have an Ombudsman poster for a period of time but after speaking with an Ombudsman the facility was able to obtain a poster and have it posted in a visible place for the residents. During the visit LPA observed the ombudsman poster posted by the entry of the facility. Based on the information obtained through interviews this allegation is deemed Substantiated.

Facility has bugs
It is alleged that the facility had cockroaches in the facility. LPA received photos of cockroaches throughout the facility. LPA during the physical plant walk through observed spider webs on the ceiling inside the facility. LPA also spoke with staff regarding this allegation. Staff indicated they have not had pest control come out but they have been spraying the facility for insects. Based on the information obtained through observation and interviews this allegation is deemed Substantiated.

Facility staff is not allowing residents to speak with visitors privately
It is alleged that facility staff was not allowing residents to meet privately with a visitors on 5/6/22. LPA spoke with a verified witness who confirmed that on 5/6/22 residents did have visitors who came to speak with the residents and confirmed residents were not allowed to speak privately with their visitors. LPA spoke with the administrator regarding this allegation. Based on the information obtained through interviews this allegation is deemed Substantiated at this time.

Residents are not being provided activities while in care.
It is alleged that residents are not being provided activities while in care. LPA conducted interviews with facility staff regarding this allegation. LPA attempted to interviews the residents but the residents were not able to understand what was being asked. During the visit LPA observed one resident to be sitting alone at the table, while another resident was just sitting on the couch, while another resident was in their bedroom. LPA interviewed staff regarding this and they stated only one person was able to do activities. Based on the information obtained through observation and interviews this allegation is deemed Substantiated.
All deficiencies are cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 31-AS-20220610145602
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: SK MARATHON HOME CARE
FACILITY NUMBER: 197609055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2022
Section Cited
CCR
87705(f)(2)
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Care Persons with Dementia-Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement was not met as evidenced by
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Corrected during the visit. Cleaning supplies were locked away during the visit.
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Based on observation during the physical plant walk through LPA observed disinfectants to be accessible to residents in care which poses an immediate health and safety risk to residents in care.
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Type A
06/13/2022
Section Cited
CCR
87468.1(a)(6)
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Personal Rights of Residents in All facilities-To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
This requirement was not met as evidenced by:
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Corrected during the visit. The devices on the doors were removed during the visit.
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Based on observation LPA observed a device on the front door of the facility and a resident bedroom which stopped residents from opening the door and would stop them from leaving the facility which poses an immediate health and safety risk to all 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: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 31-AS-20220610145602
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: SK MARATHON HOME CARE
FACILITY NUMBER: 197609055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2022
Section Cited
CCR
87470(c)
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87470(c) An Infection Control Plan shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement was not met as evidenced by:
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Administrator shall submit statement that all visitors will be Covid-19 screened before entering the facility and that facility staff shall wear mask while working. Statement shall be submitted to LPA by POC due date.
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Based on observations the licensee/staff did not comply with the cited section by not screening LPA"s for symptoms of COVID 19 upon entry and facility staff were not observed to be wearin gmask which poses and immediate Health and Safety and personal rights risk to persons in care.
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Type B
06/15/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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Administrator shall have a pest control company come and treat the facility. Administrator shall also have the facility cleaned and send a self certifying statement when this is done. Proof of pest control services obtained need to be submitted to LPA.
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Based on observation the facility was not observed to be clean and sanitary during the visit. Facility also had an issue with roaches being present in the facility.The toilet and dryer were not working for a time which posed a potential health and safety 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: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 31-AS-20220610145602
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: SK MARATHON HOME CARE
FACILITY NUMBER: 197609055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2022
Section Cited
CCR
87468.2(a)(1)
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Additional Personal Rights of Residents in Privately Operated Facilities-To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
This requirement was not met as evidenced by:
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Administrator shall submit statement that residents will have privacy when meeting with any visitor and their visitation will not be impeded by facility staff. Statement is due by POC due date.
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Based on interviews conducted residents were not able to meet privately without interruptions with visitors on 5/6/22. This poses as a potential health and safety risk to residents in care.
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Type B
06/13/2022
Section Cited
CCR
87468.2(1)
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Additional Personal Rights of Residents in Privately Operated Facilities- The licensee shall post the telephone numbers and addresses for the local offices of the State Department of Social Services and ombudsman program
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Corrected before visit. Facility obtained a LTCO poster and it is posted for residents to see.
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conspicuously in the facility foyer, lobby, residents’ activity room, or other location easily accessible to residents and their representatives. This requirement was not met as evidenced by: Based on interviews for a period of time facility did not have a poster which posed a potential health and safety 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: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 31-AS-20220610145602
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: SK MARATHON HOME CARE
FACILITY NUMBER: 197609055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2022
Section Cited
CCR
87219(a)
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Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.
This requirement was not met as evidenced by
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Administrator shall submit a planned activities calendar and signed statement that activities will be provided to residents.
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Based on interviews conducted and observation residents did not have planned activities which posed a personal rights violation 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: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7