197609873-3-26-2022-29-AS-DPEA-CCYTFV-20220329144211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609873
Report Date: 03/26/2022
Date Signed: 03/26/2022 03:32:03 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
07/15/2021 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20210715134128

FACILITY NAME:	COTTAGES OF LAKE BALBOA 3, THE		FACILITY NUMBER:	197609873
ADMINISTRATOR:	PANTELIC, PHILLIP		FACILITY TYPE:	740
ADDRESS:	6726 GAVIOTA AVE		TELEPHONE:	(747) 264-1116
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 4	DATE:	03/26/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Benjie Binuya - Caregiver		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility Resident #1 (R1) fell and sustained a fractured tibia as a result of facility lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with caregiver Benjie Binuya and explained the reason for the visit. Mr. Binuya contacted Angelie De Leon Resident Operation. Reason for visit was explained and allegation finding disccused.

On 07/15/2021, the Department receivehochiad a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility Resident 1 (R1) fell and sustained a fractured tibia as a result of facility lack of supervision. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Jose Santana.

On 07/16/2021, from 11:40am to 1:00pm, Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced initial 10-day complaint visit to the facility. LPA Smith met with Administrators David Ebrami and Justin Levi and explained the reason for the visit. The LPA conducted a tour of the physical plant, conducted a file review at 12:20pm and obtained copies of pertinent documentation. (continue to LIC9099c)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210715134128

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: COTTAGES OF LAKE BALBOA 3, THE	FACILITY NUMBER: 197609873
	VISIT DATE: 03/26/2022

NARRATIVE

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The Administrators were notified that the complaint was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Jose Santana. The LPA determined further investigation was required.

On 07/20/2021, Investigator Santana conducted interviews with the reporting party and with R1’s representative; on 07/30/2021, a follow-up interview with R1’s representative; on 08/02/2021, with Witness #1 (W1); on 08/06/2021, with R1 and Staff #2 (S2); on 08/13/2021, with facility Administrator Nicholas Saenz, Licensee and Staff #1 (S1); on 08/18/2021, with Witness #2 (W2); and on 09/02/2021, a follow-up interview with S1.

On 07/21/2021, Investigator Santana contacted the Los Angeles Police Department (LAPD) West Valley Station. The LAPD did not investigate the allegation as it did not receive an APS cross referral. On 10/19/2021, Long Term Care Ombudsman Program (LTCOP) Region II was contacted and advised that the complaint allegation was not investigated because they did not obtain the required consent to do so.

Investigator Santana reviewed copies of facility records and medical records related to R1. The admission agreement indicated R1 was admitted to the facility on 04/11/2019. The physician report, dated 08/20/2020, listed the primary diagnoses as chronic respiratory failure, hypoxia, asthma, and COPD. R1’s secondary diagnoses included osteoarthritis and osteoporosis. R1 was noted as requiring continuous bed care, was able to communicate needs and follow instructions, required use of oxygen, had mild cognitive impairment but was not typically confused. Additionally, the Investigator reviewed the Unusual Incident Reports for 07/08/2021 and 07/10/2021, caregiver notes, Emergency Medical Services (EMS) records, Valley Presbyterian Hospital, and Kaiser Permanente Panorama City records.

The facility and hospital records indicate that when the facility noticed R1 was difficult to rouse on the morning of 07/08/2021, the facility sent R1 to the hospital because it recognized a change of condition. R1 was treated for Acute-on-chronic hypoxemic respiratory failure and was discharged with oral antibiotics. On 07/10/2021, prior to R1’s hospital discharge, the last hospital entry on R1’s condition, at 3:55pm, noted R1 was awake, alert, stable and in no acute distress. The ambulance transported R1 back to the facility at 6:17pm. The Emergency Medical Technician (EMT) noted R1 was alert and oriented times four with a chief complaint of general weakness; the EMT also noted R1’s baseline was normally alert and oriented times one or two. (continue to LIC9099c)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210715134128

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: COTTAGES OF LAKE BALBOA 3, THE	FACILITY NUMBER: 197609873
	VISIT DATE: 03/26/2022

NARRATIVE

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R1 was calm and communicative during transport, but R1’s level of consciousness decreased to alert and oriented times zero in transit; R1 was otherwise in no distress. R1 arrived at the facility at 7:08pm and EMTs transferred R1 to bed via sheet transfer and left the bedrails raised and departed at 7:23pm. S1, the sole caregiver who accepted R1 at the facility, stated to Investigator Santana that despite EMT assessment, R1 was confused, R1 was as alert as usual but stated being tired.

However, it was later discovered from S1’s 911 call at 8:04pm that S1 told the operator that R1 told S1, fifteen (15) minutes prior, that R1 was confused and “did not know what was happening”. S1 failed to inform the facility Administrator of R1’s condition upon return from the hospital. After S1 left R1 in bed to attend to another resident, R1 fell while attempting to stand and fractured right tibia.

Investigator Santana asked the Licensee, Justin Levi, if R1’s confusion on facility return would have warranted a reassessment, and he informed the investigator that the facility’s entire care operation is designed to care for residents who are as confused as R1 was on return from the hospital. The level of supervision S1 would have had to provide R1 given R1’s increased confusion would have been no different from the standard level of supervision, so a reassessment would not have changed R1’s level of care. The allegation that R1 sustained injury as a result of facility Neglect/Lack of Supervision is therefore deemed Unsubstantiated at this time.

Exit interview conducted, appeal rights and a copy of this report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2022

LIC9099 (FAS) - (06/04)

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