197609932-5-9-2023-29-AS-DPEA-CSBM9G-20230530092439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609932
Report Date: 05/09/2023
Date Signed: 05/09/2023 01:36:16 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2021 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210222162936

FACILITY NAME:	KAREN'S SENIORS CARE HOME, INC.		FACILITY NUMBER:	197609932
ADMINISTRATOR:	ZINKOFSKY, BRANDON		FACILITY TYPE:	740
ADDRESS:	17610 HAYNES STREET		TELEPHONE:	(818) 205-3820
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 6	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	11:18 AM
MET WITH:	Clarita Zinkofsky		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Resident sustained multiple injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek initiated a subsequent complaint visit with the purpose of delivering findings for the allegation listed above. LPA arrived at 11:18AM and initially met with facility staff Timoteo Delacruz. Facility Designee Clarita Zinkofsky was contacted and arrived at 12:25PM. Entrance interview conducted.

During today’s visit, LPA, along with facility staff, toured the facility at 11:24AM, LPA conducted an interview with facility designee at 12:25PM, and interviewed staff between 11:28AM and 11:33AM. During an initial complaint inspection conducted virtually on 03/04/2021, LPA Dulek conducted a telephone interview with facility designee Clarita Zinkofsky at 11:55AM and the LPA requested copies of Resident #1 (R1)’s pertinent documents. Throughout the course of the investigation, LPA reviewed the pertinent documents and conducted interviews with relevant parties. The following was then determined:

Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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-20210222162936

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: 05/09/2023

NARRATIVE

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The complaint alleges that R1 sustained multiple injuries while in care. Record review revealed that R1 is ambulatory and has wandering behavior. Needs and service appraisal indicates R1 is at risk for falls related to unsteady gait. Interviews revealed that R1 had been residing at the facility for some time at the time of the complaint allegation, so the staff were familiar with R1’s care needs and behaviors at that time. Facility staff were aware of R1’s behavior and falls and had met with R1’s family members and physician approximately 7 months prior to discuss changing R1’s medication and additional care needs. At that time, licensee representative had issued a verbal eviction notice to R1’s Responsible Party (RP.) However, written notice was not issued to the RP. Following the meeting, facility staff provided additional supervision to R1 in order to mitigate unwanted behaviors and decrease R1’s fall risk, including additional visits by the facility designee. Interviews revealed that the additional supervision provided was successful, however toward the end of December 2020, staffing plans changed due to COVID and the facility designee was no longer conducting additional visits. Interview revealed that R1 fell around 4:30AM on 02/16/2021. Staff informed facility designee via telephone and facility designee visited the facility at 2:00PM and observed bruising on R1’s arm. This incident was not reported to CCL, nor was documentation of notification to R1’s physician provided. Interview also revealed that R1’s responsible party was not informed of this fall. Additionally, the facility did not conduct a needs and service appraisal identifying R1’s changing needs nor was additional supervision provided to R1 although previous additional supervision was successful in limiting R1’s behaviors and fall incidences. Then, on 02/20/2021 at 04:00AM, R1 fell a second time, resulting in bruising on R1’s forehead. Facility designee was informed via telephone and arrived at the facility around 01:00 or 02:00PM to observe the resident’s bruising. At that time, the facility staff called 9-1-1 and R1 was taken to the hospital for further evaluation. Based on interview and record review, there is sufficient evidence to support the allegation, therefore, the allegation that “resident sustained multiple injuries while in care” is deemed SUBSTANTIATED at this time.

The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $1000. Facility designee was informed that failure to correct the deficiency may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210222162936

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: 05/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/10/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 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:	1 2 3 4 5 6 7	Facility designee will provide LPA with a copy of the documents previously provided to LPA Balisi on 10/10/2022 regarding the facility's care and supervision plan. Designee will provide to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the above cited section as proper supervision was not provided to R1, resulting in falls and R1 sustaining multiple bruises, which posed an immediate health and safety risk to residents in care. Civil penalty issued.	8 9 10 11 12 13 14
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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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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