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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703748
Report Date: 10/14/2022
Date Signed: 10/15/2022 06:11:02 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
01/03/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220103090234
FACILITY NAME:PURISIMA HILLSFACILITY NUMBER:
421703748
ADMINISTRATOR:SUSAN MARSHFACILITY TYPE:
740
ADDRESS:237 ALDEBARAN AVENUETELEPHONE:
(805) 733-4395
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:6CENSUS: 3DATE:
10/14/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Licensee / Susan MarshTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Staff are not following COVID-19 guidelines.
INVESTIGATION FINDINGS:
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13
 At 230pm on 10/14/2022, Licensing Program Analyst (LPA) Jeffries arrived unannouced at the facility to return orignal documents and to issue final findings to the allegigations to this complaint. LPA met with Licensee Susan Marsh and announced the reason for the visit.

As to the allegation of, “Staff are not following COVID-19 guidelines.” It was alleged that persons entering the facility were not screened for COVID-19 symptoms. LPA interviewed medical personnel, who stated they were not screened for COVID-19; however, medical personnel were not required to be screened for COVID-19. On 10/03/2022 LPA requested from the facility Licensee, “COVID-19 screening and sign-in records from January 2022 or other COVID-19 screening protocols the facility documented during January 2022” on LIC9099 dated 10/03/2022. On 10/11/2022, LPA made a second request by telephone to S1. S1 stated that visitors were screened but does not have the sign in records. Licensee did have more recent sign-in records. LPA noted that on a visit conducted on 10/03/2022, S1 was in the facility not wearing a mask, although no other residents were present inside the facility and one resident was sitting outside. CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
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-20220103090234
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: PURISIMA HILLS
FACILITY NUMBER: 421703748
VISIT DATE: 10/14/2022
NARRATIVE
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 LPA requested S1 put on a mask during the visit and S1 stated, “Ha’ha.’” On 10/06/2022, LPA was asked to sign in. Licensee was unable to provide sign-in and screening records from January 2022. Based on interviews and documentation, the allegation of, “Staff are not following COVID-19 guidelines” is substantiated at this time. Technical Assistance is issued in lieu of a citation.

Exit interview, report singed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/03/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220103090234

FACILITY NAME:PURISIMA HILLSFACILITY NUMBER:
421703748
ADMINISTRATOR:SUSAN MARSHFACILITY TYPE:
740
ADDRESS:237 ALDEBARAN AVENUETELEPHONE:
(805) 733-4395
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:6CENSUS: 3DATE:
10/14/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Licensee / Susan MarshTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident left in soiled diaper resulting in resident sustaining a rash.
Resident's medications are not properly stored.
Staff left resident's unattended.
Staff are not properly trained.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 At 230pm on 10/14/2022, Licensing Program Analyst (LPA) Jeffries arrived unannouced at the facility to return orignal documents and to issue final findings to the allegigations to this complaint. LPA met with Licensee Susan Marsh and announced the reason for the visit.

As to the allegation of, “Resident left in a soiled diaper resulting in resident sustaining a rash.” It was found through interviews and documentation that R1 was assisted with toileting by facility staff at least five times per day (twice in the AM shift, twice in the PM shift and once in the Overnight shift) on a daily basis, according to facility daily shift notes, dating from January 4, 2022, through January 26, 2022. On 10/04/2022 at 3:30pm, an interview with Person 1 (P1) stated that they were verbally informed by Person 2 (P2) to have found R1 in a soiled diaper at an unspecified time on 12/31/2021. There was a total of twelve visits by P1, P2, and Person 3 (P3), during the time period on December 22, 2021, and January 28, 2022, during that time there was one recorded instance of R1 having a soiled diaper. P1 also reviewed hospice notes over the phone with the LPA, and stated there are no Hospice notes that indicate R1 had a rash. CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
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 5
Control Number 29-AS-20220103090234
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: PURISIMA HILLS
FACILITY NUMBER: 421703748
VISIT DATE: 10/14/2022
NARRATIVE
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 There were also no notes expressing concerns about the soiled diaper. Interview with S1 indicated that R1 was changed as needed and checked regularly throughout the day. Based on interviews, and documentation there is not enough evidence at this time to support the allegation of, “Resident left in a soiled diaper resulting in resident sustaining a rash.” and is unsubstantiated at this time.

As to the allegation of, “Resident’s medications are not properly stored.” LPA visited the facility at 10:30am on 10/03/2022 and conducted an unannounced facility visit and tour of the facility. During that facility tour, LPA observed facility medication was secured in the living room/kitchen room area in a locked storage cabinet and securely locked with a padlock. Additionally, there is a small refrigerator in a facility closet that was also observed by the LPA to be securely locked with a padlock. In an interview at 3:30pm on 10/04/2022, P1 stated that facility staff did not show P1, P2 or P3 where the medication was being stored, P1 did not recall the conversation, only feeling uncomfortable about the storage of the medication. In an interview with S1 at 11:15am on 10/03/2022, when LPA asked about medication storage and hospice medication and training, S1 stated that they had been doing this (hospice medication training) for 32 years.” On 10/06/2022, S1 provided documentation from VNA Health dated 08/12/2020 of certified hospice training for -Turning, -Incontinence Care to Prevent Skin Breakdown, -Proper Hydration, -Infection Control and -Pain and Symptom Management, with S1, S2 and S3 noted on that training. Based on observations of the medication storage being secure and interviews at this time there is not enough evidence to support the allegation of, “Resident’s medications are not properly stored. and is unsubstantiated at this time.

As to the allegation of, “Staff left residents unattended.” It was discovered through interviews and documentation that interview conducted at 3:30pm on 10/04/2022, P1 stated that on one of their visits to the facility the only caregiver went to the house next door and left R1 alone with P1 in the facility for an unknown amount of time. P1 stated that visits are about an hour depending on condition of the patient. LPA reviewed physician’s reports for the three residents who lived in the facility at the time. Only R1 needed supervision by staff. During this incident, R1 was with P1 in a private medical appointment at the time the staff went to the facility located next door for an undisclosed amount of time. Based on interview and record review, the allegation of, “Staff left resident unattended” and is unsubstantiated at this time. Technical Advisory is issued that facility staff should always be present at the facility and available to residents.

CONTINUED on LIC9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20220103090234
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: PURISIMA HILLS
FACILITY NUMBER: 421703748
VISIT DATE: 10/14/2022
NARRATIVE
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2
3
4
5
6
7
8
9
10
11
12
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 As to the allegation of, “Staff are not properly trained.” It was discovered through interviews and documentation that on the interview conducted at 3:30pm on 10/04/2022, P1 stated that the staff at the facility did not communicate that they were trained in hospice care or hospice medication management. P1 also stated that they did pre-draw oral syringes for hospice medications and provided the predawn syringes to S1 for R1’s hospice medication needs. In an interview at 11:15am, on 10/03/2022, when LPA requested documentation for hospice care training and hospice medication training, S1 stated that, “I’ve been doing this for 32 years, I am sure I have something.” On 10/06/2022, S1 provided documentation from VNA Health dated 08/12/2020 of certified training for -Turning, -Incontinence Care to Prevent Skin Breakdown, -Proper Hydration, -Infection Control and -Pain and Symptom Management, with S1, S2 and S3 noted on that training. This training met the training requirement for hospice services. Based on interviews and documentation there is not enough evidence at this time to support the allegation of, “Staff are not properly trained.” is unsubstantiated at this time.

Exit interview, report signed, and report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5