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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609932
Report Date: 10/07/2022
Date Signed: 10/07/2022 10:55:25 AM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20220503165055
FACILITY NAME:KAREN'S SENIORS CARE HOME, INC.FACILITY NUMBER:
197609932
ADMINISTRATOR:ZINKOFSKY, BRANDONFACILITY TYPE:
740
ADDRESS:17610 HAYNES STREETTELEPHONE:
(818) 205-3820
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 5DATE:
10/07/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Brandon ZinkofskyTIME COMPLETED:
11:15 PM
ALLEGATION(S):
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Resident sustained an unwitnessed fall resulting in injuries.

Facility failed to seek medical attention in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial complaint visit was conducted on 05/04/2022 by LPA Zabel Chochian. During today’s visit, Upon arrival at approximately 9:30am, LPA was screened by staff. At approximately 10:30am, LPA met with Administrator Brandon Zinkofsky and explained the reason for the visit.
On 05/03/2022, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that while under facility care, Resident #1 (R1) sustained an unwitnessed fall resulting in fractures to the tibia, fibula, proximal fibula to left leg and medical attention was not sought for R1 in a timely manner. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Laura Garcia.

On 05/04/2022, between 3:00pm and 4:30pm, LPA Chochian conducted the initial 10-day complaint visit. The LPA met with staff upon arrival and explained the reason for the visit. Staff contacted owner/assistant administrator Clarity Zinkofsky.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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 5
Control Number 29-AS-20220503165055
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: KAREN'S SENIORS CARE HOME, INC.
FACILITY NUMBER: 197609932
VISIT DATE: 10/07/2022
NARRATIVE
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Continued from 9099
At approximately 3:15pm, the LPA and staff toured the facility indoors/outdoors; LPA conducted a file review and obtained copies of pertinent documentation at approximately 3:30pm.

Investigator Garcia attempted to conduct interviews with the administrator on 05/06/2022 and 06/06/2022. On 06/10/2022, at approximately 4:30pm, conducted interview with the administrator; on 05/06/2022 attempted to conduct an interview with the assistant administrator; on 07/07/2022, at approximately 6:00pm, conducted interview with assistant administrator; on 07/06/2022, at approximately 1:00pm, and on 07/29/2022 at approximately 4:00pm, attempted interview with Staff #2 (S2); on 08/09/2022, from approximately 10:30am to 12:30pm, conducted interviews with assistant administrator, Staff #1 (S1), R1, and Resident #2 (R2); on 09/08/2022, from approximately 10:00am to 3:40pm, conducted interviews with S2, and R1’s resident representatives; and on 09/14/2022, at approximately 12:00pm, conducted an interview with Witness #1 (W1). Additionally, Investigator Garcia reviewed copies of medical records and photographs of R1’s injuries.

The investigation revealed that on 05/01/2022, R1 sustained an unwitnessed fall. According to the Unusual Incident Report, on 05/01/2022, the staff placed R1 on the commode at approximately 3:30pm and then found R1 on the floor approximately 3:30pm. Per the staff, R1 denied pain and did not receive immediate medical care. Per the assistant administrator, the next day, she assessed R1 sitting in a wheelchair with slight pain noted on the left leg. R1’s resident representative was notified to have R1 evaluated at urgent care. The assistant administrator stated they called the taxi service and requested transportation for R1. At approximately 5:00pm she received a phone call from the taxi service advising her they were no longer providing transport services for the residents. Investigator Garcia contacted the taxi company and it reflected that there was no records the facility had called or placed an order. At 5:00pm the caregivers informed her that R1 was ok and did not need to go to the hospital. She advised the staff to observe R1 for the night. On 05/03/2022, at 7:30am, S2 called the assistant administrator to report swelling with bruising on R1’s left leg and texted a photo. At 8:30am, staff were informed to not move R1, give Tylenol and call 911. R1’s resident representative was notified and R1 was sent to the hospital.

The Kaiser Permanente medical records reviewed indicate on 05/03/2022, at 10:00am, R1 was presented to the hospital for evaluation following a fall. R1 reported a ground level fall in the bathroom (1) week ago.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220503165055
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: KAREN'S SENIORS CARE HOME, INC.
FACILITY NUMBER: 197609932
VISIT DATE: 10/07/2022
NARRATIVE
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Continued from 9099-C

R1 noted lower extremity pain, swelling and bruising to the left ankle and lower leg prompting presentation to the Emergency Department for further evaluation. R1 stated they are usually wheelchair bound and does not ambulate. It was notated that R1 has a history of falls and unsteady gait. X-rays were taken and demonstrated fracture of the distal tibia, fibula and proximal fibula. Physician discussed with R1 that typically this fracture pattern indicates surgery for maintenance of alignment and ankle stability. However, since R1 was non-ambulatory with medical comorbidities that make risks of surgery outweigh the benefits. R1 agreed and was placed in a cast and discharged back to the facility.

The hospital records also noted neglect issues. It was revealed that while R1 was assessed at the hospital, the social worker (LCSW) contacted the assistant administrator to inquire if R1 had fallen a week ago. The assistant administrator reported that R1 fell the day before yesterday (05/01/2022) and did not believe R1 had a fall a week ago, but that R1 was seen crawling on the bathroom floor a week ago. Assistant administrator stated they assessed R1 and R1 did not report having any pain. The LCSW received a referral from the bedside RN due to concerns about R1’s fall. Per the RN, R1’s bruising appeared to be in different stages of healing. Per chart review R1 fell while transferring to a wheelchair over a week ago.

During the interview with investigator Garcia, R1 stated that on one occasion they fell off the bed and that they kept screaming for help because they don’t have any type of emergency alarms in the bedrooms. R1 stated that two staff came into the room and assisted R1 back to the bed. But R1 reiterated they kept telling the staff that they wanted to go to the hospital because they were in so much pain. R1 stated they kept complaining to the staff, but they did not listen. R1 stated they ended up taking R1 several days after, and when the hospital took x-rays they saw several fractures.

Information obtained through interviews found that staff were unable to provide consistent statements regarding the appropriate level of care provided to R1. Additionally, they were unable to provide any notes regarding R1’s care, R1’s leg/foot condition, Doctor’s recommendations, or supervision logs. The staff stated that when R1 was found on the floor, R1 did not complain of any pain, therefore, no medical attention was immediately sought. The staff were aware that R1 was a fall risk and confirmed that in several occasions, R1 “would slide off” bed and was found crawling on the floor. Vague statements were provided regarding the level of care and appropriate safety measures in order to prevent further injuries.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20220503165055
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: KAREN'S SENIORS CARE HOME, INC.
FACILITY NUMBER: 197609932
VISIT DATE: 10/07/2022
NARRATIVE
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Continued from 9099-C

Based on the statements provided, documentation and photographs obtained, the Department has sufficient evidence to support the allegations. Therefore, the above allegations, “ Resident sustained an unwitnessed fall resulting in injuries” and “Facility failed to seek medical attention in a timely manner” are deemed SUBSTANTIATED at this time.

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

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)


Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20220503165055
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: KAREN'S SENIORS CARE HOME, INC.
FACILITY NUMBER: 197609932
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/10/2022
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services.
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c).
This requirement is not met as evidenced by:
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Licensee will submit a written action plan regarding proper resident care and supervision to CCL by COB Monday 10/8/2022 via email.
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Based on interviews and records review, the licensee did not comply with the section cited above. (R1) was not provided the proper supervision to ensure R1’s safety. R1 had a history of falls, which led to R1 sustaining fractures to tibia, fibula, proximal fibula to left leg from a fall(s), which posed an immediate health and safety risk to residents in care.
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Request Denied
Type A
10/10/2022
Section Cited
CCR
87465(a)(1)
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87465(a)(1) A plan for incidental medical and dental care shall be developed by each facility. The plan shall...(1) The licensee shall arrange, or assist in arranging, for medical...conditions and needs of residents.

This requirement is not met as evidenced by:
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Licensee will submit plan how you will ensure residents receive timely medical care. Submit to CCL by COB Monday 10/8/2022 via email.
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Based on interviews, the licensee did not comply with the section cited above. The administrator did not take action to have R1 transported to a medical facility for 2 days after R1 fell off commode and was found on floor, which posed an immediate 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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5