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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609562
Report Date: 03/03/2023
Date Signed: 03/03/2023 03:57:12 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
02/22/2023 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20230222153500
FACILITY NAME:APPLEGATE @ SIRIUSFACILITY NUMBER:
197609562
ADMINISTRATOR:CARMONA, IRMAFACILITY TYPE:
740
ADDRESS:2614 SIRIUS STREETTELEPHONE:
(805) 380-9400
CITY:THOUSANDS OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Emma CarmonaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff leave resident in dirty diapers for extended periods
Resident sustained multiple UTIs while in care
Staff failed to keep resident adequately hydrated
Staff failed to administer resident's medication as prescribed
Staff failed to provide adequate food service
Staff leave resident unattended for extended periods
Staff refused to allow home health care nurse to visit resident
Residents are not being provided activities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Elsie Campos conducted an subsequent complaint visit regarding the above mentioned allegations to deliver the findings. LPA met with Administrator, Emma Carmona and explained the reason fo the visit. During the initial visit conducted on 3/1/2023, the LPA spoke with hospice nurse the at about 10:00 a.m. Interviwed staff at 9:40 a.m.,10:25 a.m., 11:00 a.m, doctor's office 12:41 p.m. and resident family member at 2:00 p.m. and 3:30p.m. LPA interviewed residents at 12:21 p.m., 12:30 p.m., 3:15 p.m. 3:25 p.m. 3:35 p.m and 3:37 p.m. Today, the LPA the delivered the findings.

Allegation: Staff leave resident in dirty diapers for extended periods
It was alleged that Resident #1 (R1's) incontinent needs were not met, resulting in staff leaving R1 in dirty diapers for extended periods. **Continued on LIC 9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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-20230222153500
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: APPLEGATE @ SIRIUS
FACILITY NUMBER: 197609562
VISIT DATE: 03/03/2023
NARRATIVE
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 Interviews revealed that facility staff were responsible for tending to R1’s care needs both day and night. LPA observed R1 at the time of the visit and R1 did not appear distressed, unwell, or soaked in urine. Interviews with witnesses confirmed that when visiting R1 unannounced at random hours and times R1 was never observed to be soaked in urine.
Out of a current census of six (6), all residents require assistance with incontinence care. Staff interviews revealed that residents are checked on at least every two to three hours to ensure that incontinent needs are met timely. Staff and witnesses agreed that resident needs are tended to in a timely manner. Interviews revealed that staff are responsive in meeting the toileting needs of the residents and are communicative with one another if they need assistance with changing or refreshing a resident. Interviews with resident’s did not reveal any concerns and they did not confirm they were being left unattended or in dirty diapers for extended periods of time. Lastly, interviews revealed that residents are regularly checked for skin breakdown or the presence of wounds, which none of the residents have at the time of this visit. Evidence obtained showed no skin breakdown. Based on the information obtained, there is insufficient evidence to support the claim that due to lack of care and supervision, R1 was left in dirty diapers for extended periods. Despite being checked and refreshed within a two hour time frame, R1 - or any resident - can soil their clothing soon after being checked. This allegation is deemed Unsubstantiated at this time.

Allegation: Resident sustained multiple UTIs while in care
The complainant alleged that Resident #1 (R1) sustained multiple Urinary Tract Infections (UTI’s) at the facility and for this reason R1 sustained multiple UTI’s while in care. Interviews with the Administrator revealed, that R1 has a history of chronic UTI. Witness interviews further confirmed that R1 has suffered from UTI’s since mid-adulthood. Witness interviews further revealed that the facility has been made aware that should R1 have a suspected UTI, the best course of action would be to monitor for severe UTI symptoms, at which time testing and medication would be requested. Staff interviews revealed that staff were attentive in providing R1 with adequate care, which included regular changing and diapering needs, providing R1 with diapering 3-4 times a day and throughout the night. Although R1 is unable to communicate if their water container needs to be replenished, R1 is consistently encouraged to drink water when staff check on them. In addition, liquids are provided at every mealtime and in between. During the visits to the facility, the LPA observed that R1 had a sufficient supply of liquids available in their room by their bedside within reach. Based on the information obtained, there is insufficient evidence to support the allegation resident sustained multiple UTI’s while in care. Therefore, the allegation is deemed Unsubstantiated at this time. **Continued on LIC 9099-C**
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20230222153500
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: APPLEGATE @ SIRIUS
FACILITY NUMBER: 197609562
VISIT DATE: 03/03/2023
NARRATIVE
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Allegation: Staff failed to keep resident adequately hydrated
It was alleged that facility staff failed to keep Resident #1 (R1) hydrated, as R1 is usually dehydrated. Interviews conducted with witnesses revealed that R1 has access to water at all times. Although R1 is unable to communicate if their water container needs to be replenished, R1 is consistently encouraged to drink water when staff check on them. In addition, liquids are provided at every mealtime and in between. During the facility visit, the LPA observed that R1 had a sufficient supply of liquids available in their room by their bedside within reach. The LPA further observed all other resident’s in the facility and confirmed that they were drinking water at the time of observation or had water available within reach. Interviews conducted with facility staff and residents did not provide sufficient evidence to support the claim that the facility was negligent in providing adequate hydration for residents. An interview with the home health nurse did not reveal that R1’s ability to consume fluids or foods were a concern. Staff can only offer liquids to residents and prompt them to drink; however, if the resident does not want to drink liquids at that time, they can’t be forced to do so. Should staff have any concerns regarding a resident failing to consume liquids for a significant period of time, the resident’s physician should be notified. In this particular case regarding R1, the LPA found that R1 had water near their bed side and within reach. An interview with R1’s assigned home health nurse did not reveal any concerns regarding hydration and indicated that R1 is hydrated and has radiant and clear skin. Based on the investigation, there is insufficient evidence to support the claim that the facility failed to keep resident adequately hydrated. The allegation is deemed Unsubstantiated at this time.

Allegation: Staff failed to administer resident's medication as prescribed
It was alleged that R1 was prescribed medication, but the staff failed to assist the resident with the self-administration of the medication. The complainant alleges that the medication prescribed for UTI on 12/28/2022 was not provided to the resident on time. A review of facility notes and copy of prescription revealed that R1 was prescribed a medication for a UTI on 12/28/2022. Evidence obtained confirmed that the medication was ready for pick up on 12/28/2022; however, there was only one (1) hour left in the day for medication pick up. Text messages dated 12/28/2022 confirmed that R1’s responsible party and care team agreed to having R1’s medication delivered the following day, with no complications to R1’s condition. A review of R1’s Medication Administration Record (eMAR) for the months of December 2022 through January 2023 indicated that R1 was provided the medication for self-administration timely on 12/29/2022 and regularly until the medication was completed. **Continued on LIC 9099-C**
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 29-AS-20230222153500
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: APPLEGATE @ SIRIUS
FACILITY NUMBER: 197609562
VISIT DATE: 03/03/2023
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An order was signed by R1’s physician on 12/28/2022, indicating that R1 was to take the medication for a total of five (5) days and discontinued thereafter. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to provide medication for R1 to self administer as prescribed. This allegation is deemed Unsubstantiated at this time.

Allegation: Staff failed to provide adequate food service


It was alleged that the quality of the food the facility serves to the residents is poor. Interviews with R1’s family member revealed that the food served to R1 was nutritional and of good quality, and no concerns were communicated regarding food service. In addition, information obtained from interviews with residents, staff and witnesses did not corroborate claims that food served at the facility was of poor quality nor an insufficient amount. Information obtained from interviews revealed that R1’s family also brings R1 preferred food items, such as R1s favorite butters, jam’s, and certain beverages. Family and staff confirmed any food items that are brought in specifically for R1 are labeled and stored for R1. R1’s family further confirmed that although they bring specific food items for R1, the facility has permission to share those items with the other resident’s if they wish. Staff confirmed that any special items that R1 prefers are replenished by the family or the facility. The LPA additionally observed the refrigerator which had specific food items labeled for R1 and were observed to be in good condition. Based on the information obtained, there is insufficient evidence to support the claim that the facility failed to provide adequate food service. The allegation is deemed Unsubstantiated at this time.

Allegation: Staff leave resident unattended for extended periods
It was alleged that staff leave Resident #1 (R1) unattended for extended periods of time, up to 4-6 hours. Interviews revealed that facility staff were responsible for tending to R1’s care needs both day and night. LPA observed R1 at the time of the visit and R1 did not appear distressed, unwell, or unattended. Interviews with witnesses confirmed that when visiting R1, staff regularly check in on the resident to ensure that their needs are met. Staff interviews revealed that residents are checked on at least every two to three hours to ensure that incontinent needs and any other needs are met timely. Staff and witnesses agreed that resident needs are tended to in a timely manner. Interviews revealed that staff are responsive in meeting the needs of the residents and that staff are communicative with one another if they need assistance with changing or refreshing a resident. **Continued on LIC-9099-C**
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20230222153500
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: APPLEGATE @ SIRIUS
FACILITY NUMBER: 197609562
VISIT DATE: 03/03/2023
NARRATIVE
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 Interviews with residents did not reveal any concerns regarding staff leaving them unattended for extended periods. Interviews with residents stated that staff check on them often. Based on the information obtained, there is insufficient evidence to support the claim that staff leave resident unattended for extended periods. The allegation is deemed Unsubstantiated at this time.

Allegation: Staff refused to allow home health care nurse to visit resident
It was alleged that the facility staff refused to allow the home health care nurse to visit R1. Interviews revealed that home health nurse #1 (N1) had been assigned to conduct Urinary Tract Infection testing on R1 in December of 2022. N1 was assigned to R1 as R1’s long time home health nurse was not available at the time. Interviews and record review revealed that an order was given on 12/20/22 by R1’s physician to obtain a urine sample with an in and out catheter to test for a possible UTI. This was the only order requested by the physician. Interviews revealed that N1 had returned to the facility to perform a 2nd Urinary Tract Infection test on R1 without prior notice to the facility or approval from R1’s RP. The order for the 2nd test was not requested by the physician rather it was requested by N1 on 1/9/2023. The physician signed the order on 1/10/23; however, the order did not specify that the urine sample was to be taken via an in and out catheter, which N1 did anyway without the consent of the family or facility administration. On or about 2/3/2023, the administrator was notified by staff that N1 had returned to the facility and again obtained a Urine Sample via in and out catheter; however, on this occasion, when staff asked N1 for the order it was not provided as they did not have knowledge of new order being requested. The facility administrator informed R1's family and physician who revealed that the physician had not ordered a 3rd urine sample.

Due to the circumstances and revelations that N1 was obtaining urine samples via catheter from R1 without prior notice to the facility, the physician or R1’s responsible party (RP), the facility administration along with the consent of the RP requested with the home health agency to have N1 no longer see R1 and to be seen by their usual long standing home health nurse. Staff stated that at no point was N1 denied entry to the facility or to see R1. Staff communicated that they understood the parameters for allowing visitation. Staff denied claims that residents were denied visitation per protocol. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that staff refused to allow home health care nurse to visit resident. This allegation is deemed Unsubstantiated at this time.
**Continued on LIC-9009-C**
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20230222153500
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: APPLEGATE @ SIRIUS
FACILITY NUMBER: 197609562
VISIT DATE: 03/03/2023
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Allegation: Residents are not being provided activities
Regarding the allegation that staff did not have activities for the residents and that they mostly stay in their rooms, staff interviews revealed that the facility encourages daily activities; and, while not all residents are willing to participate, those who are willing to participate will go on walks, come out to the living room, and watch T.V., read books and participate in small leisure activities. Staff noted that all residents are encouraged to attend activities and staff will encourage residents to participate if the resident is up for it. Due to the decline in R1’s condition R1 is unable to participate in any physical activity; however, R1 enjoys watching T.V. and using their telephone. Staff additionally claimed that the residents would oftentimes stay in their room and preferred to participate in solo activities, such as reading the newspaper in their room. During the initial visit on 3/1/2023, the LPA observed one (1) resident watching T.V. in the common living room, a 2nd resident taking a walk and doing small exercises with a companion in the backyard and a 3rd resident actively watching T.V. in their room. Interviews with residents confirmed that T.V. or reading is enjoyable for them and they choose to stay in their room. Based on the information obtained, there is insufficient evidence to support claims that residents are not being provided activities. 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: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6