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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609943
Report Date: 10/07/2021
Date Signed: 10/07/2021 02:58:20 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2020 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20200506102811
FACILITY NAME:JOCELYN'S LOVING CAREFACILITY NUMBER:
197609943
ADMINISTRATOR:ESPIRITU, JOCELYNFACILITY TYPE:
740
ADDRESS:803 N GENESEE AVETELEPHONE:
(323) 879-9735
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:6CENSUS: 6DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Jocelyn EspirituTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility staff neglected resident resulting in pressure injury.

Staff did not provide proper care for resident.
INVESTIGATION FINDINGS:
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It was alleged that resident #1 (R1) developed pressure injury on the left heel, due to staff not following physician order.
During course of investigation on 05/08/2020 between 8:00am and 8:30am LPA Margaryan spoke with two facility staff. At 8:45am LPA spoke with the Administrator. Staff indicated that they were not involved in R1’s wound care. R1 developed a pressure injury on their right heel sometime in February 2019 and started to receive a wound treatment by the home health care staff. Although, staff was following nurses order and elevating R1’s foot, the wound became unstageable and was debrided by the wound care doctor.
On 05/27/2019 LPA Margaryan spoke with the home health care supervisor, who verified the information received from the staff. On 06/09/2020 at 2:30pm, LPA Margaryan reviewed R1’s home health care records previously requested and received from the home health care agency. A review of medical records verified the information received from the staff. Based on interviews and record review, there is no sufficient information to support the allegation, Therefore, the allegation is UNSUBSTANTIATED at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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 4
Control Number 31-AS-20200506102811
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: JOCELYN'S LOVING CARE
FACILITY NUMBER: 197609943
VISIT DATE: 10/07/2021
NARRATIVE
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-Staff did not provide proper care for resident:

The complainant was alleging that staff did not provide proper care to R1 which resulting in an infection.
During course of investigation on 05/08/2020 between 8:00am and 8:30am LPA Margaryan spoke with two facility staff, who was assisting R1 at the facility. Staff indicated that R1 had edema on their left leg and was receiving home health care services. Staff was trying to ensure that R1’s feet were elevated as much as possible. However, at time R1 was not cooperating and not letting staff put pillows under R1’s legs to keep their feet elevated. Sometime in November 2019, due to an accident, R1 hit their left foot on the stool and had a small laceration on left shin. R1‘s responsible party took R1 to the doctor assuming that the wound was infected. The wound was never infected. To avoid possible infection the doctor prescribed triple antibiotic treatment which was provided by the home health care providers. On 05/27/2019 LPA Margaryan spoke with the home health care supervisor, who verified the information received from the staff, a review of home health care records conducted on 06/09/2020 at 2:30pm, verified the information received from the staff.
Based on interviews and record review, there is no sufficient information to support the allegation, Therefore, the allegation is UNSUBSTANTIATED at this time.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
05/06/2020 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20200506102811

FACILITY NAME:JOCELYN'S LOVING CAREFACILITY NUMBER:
197609943
ADMINISTRATOR:ESPIRITU, JOCELYNFACILITY TYPE:
740
ADDRESS:803 N GENESEE AVETELEPHONE:
(323) 879-9735
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:6CENSUS: 6DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Jocelyn EspirituTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff sleep in common areas of the facility.
INVESTIGATION FINDINGS:
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Concerns were addressed that facility has 2 full-time caregivers who are in the facility 24/7, sleeping on the couch.
During course of investigation on 05/08/2020 between 8:00am and 8:30am LPA Margaryan spoke with two facility staff: staff #1 (S1) and staff #2 (S2). Interviews revealed that both staff members are staying in the facility. S1 and S2 are rotating their schedule to work night shift. S1 is sleeping in the large closet space on the rolling bed and S2 is sleeping in the living room on the couch. On 05/08/2020 with the assistance of the staff LPA inspected the facility via face time. As per inspection all bedrooms were occupied by the residents. On 06/09/2020 at 3:00pm, LPA reviewed the facility sketch. As per floor plan, there is no room assigned to the staff.
The information received during this investigation verifies the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Under Title 22, Division 6, chapter 8, following citations were issued and recorded on LIC9099D.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20200506102811
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: JOCELYN'S LOVING CARE
FACILITY NUMBER: 197609943
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2021
Section Cited
CCR
87307(a)
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Personal Accommodations and Services. A facility’s buildings and grounds shall have no other purpose than those related to the care, comfort and privacy of the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by; Based on inspection, observation and
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Licensee has submitted a new facility sketch identifying that room number three (3) is designated as a staff room. This citation is cleared during this visit.
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interview, the licensee did not comply with the section cited above. The two live in staff are sleeping in the large closet space and on the sofa located in the common area. This poses a potential health and safety and personal rights 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: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4