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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703748
Report Date: 09/23/2024
Date Signed: 09/23/2024 12:15:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
11/27/2023 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20231127090429
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:
09/23/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Susan Marsh, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff failed to provide proper care and supervision for resident
Staff did not seek medical attention for resident
Staff violated residents visitation rights
Facility failed to update responsible party on resident's status
INVESTIGATION FINDINGS:
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On 9/23/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Administrator Sue Marsh and explained the reason for the visit.

On the allegation: Staff failed to provide proper care and supervision for resident. It is alleged that on 10/07/2022, Resident #1 (R1) had eloped from the facility without staff supervision and without the use of a wheelchair. The responsible party for R1 indicated that R1 always needs the use of a wheelchair when outside of the facility. Additionally, it is alleged that on 09/09/2023, R1 eloped from the facility without staff knowledge and without the use of a wheelchair. R1 fell during this elopement causing head, arm, and hand trauma which bled profusely. A neighbor of the facility found R1, contacted 911, and returned R1 to the facility as staff allegedly would not leave the facility to aid. Allegedly staff lied to the responsible party of R1 about the distance R1 eloped on 09/09/2023. Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
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 10
Control Number 29-AS-20231127090429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748
VISIT DATE: 09/23/2024
NARRATIVE
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According to the allegation R1 had a fall in the facility in early 2022 and staff were unable to pick R1 up. The staff had to allegedly get another resident out of bed to help pick up R1 off the floor. Allegedly staff allowed R1 to wander freely in the facility while staff sat in another room, even when R1 was the only resident in the facility while other residents attended day program off site.

On 11/28/2023, Licensing Program Analyst (LPA) conducted an initial complaint investigation visit to the facility above. During this visit, LPA requested and received relevant facility documentation pertinent to the allegation above for record review. LPA received R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) signed and dated 03/01/2022. Under R1’s Mental Condition it is documented that R1 does not have wandering behavior, does not have confused/disoriented behavior, and is able to leave the facility unassisted. Under R1’s Physical Health Status it is noted that R1 has visual impairment, auditory impairment, but does not have motor impairment/paralysis. Under R1’s capacity for self-care it is noted that R1 needs facility staff stand by assistance with transfers to/from the bath. The ambulatory status of R1 states that they can transfer to and from bed but need staff supervision for stand by assistance. The admission agreement to the facility for R1 signed and dated on 02/24/2022 indicates that R1 will receive assistance with personal activities of daily living including mobility tasks. The documented resident appraisal for R1 while in care indicates that R1 has physical disabilities including needing staff assistance to stand and vision loss/degenerative blindness. The resident appraisal of R1 indicates the functional capabilities of R1 as frail or slow, difficulty climbing or descending stairs, requirement of grab bars in bathroom, and that R1 uses a wheelchair. R1 had a facility documented fall in care on 10/09/2022, and on 10/22/2022 a documented hospital referral for R1 Physical Therapy indicated that R1 was referred to evaluate and treat frequent falls as well as unsteady gait from 10/18/2022 through 10/18/2023. The Appraisal/Needs and Services (ANS) Plans for R1 dated 04/01/2022 and 11/10/2022 document under R1’s physical health that they use a wheelchair and/or walker within the facility but have a mandatory wheelchair for the outdoor areas of the facility and on excursions. The persons responsible for implementation are indicated as all staff in the facility.

Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated.

Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 29-AS-20231127090429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748
VISIT DATE: 09/23/2024
NARRATIVE
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On the allegation: Staff did not seek medical attention for resident. It is alleged that when the responsible party for R1 did not visit the facility for long periods of time, they would return to the facility to find R1 picking at their face with dried blood on their face and neck which staff attempted to cover with band aids. According to the allegation, staff stated that the incident had occurred due to R1’s mental state but failed to provide care for mental health issues.

On 11/28/2023, LPA was provided with narrative charting for a Record of Medical and Dental Care of R1 during the year of 2022. On 11/02/2022, R1 was sitting outside facility on the front porch area waiting for their responsible party to come and pick them up. When the responsible party for R1 arrived, they found R1 unresponsive. The responsible party had to alert the administrator in the facility to come and observe. Staff informed the responsible party of R1 that they had just had contact with R1, and informed responsible party of R1 that R1 was napping on the porch of the facility. However, when paramedics arrived after responsible party called 911, they determined R1 had very low blood pressure and irregular heartbeat. R1 was admitted to the hospital. LPA received documented hospital discharge paperwork for R1 from 11/02/2022 after the unresponsive incident regarding R1 on 11/02/2022. R1 was admitted for observation, low blood pressure, and arrhythmia. Additionally, LPA received a record of medical and dental visits for the facility from 02/20/2023 regarding the first aid care attempted by the facility on the scratches on R1’s face. There is no evidence the primary care physician of R1 requested mental health services for R1. LPA received R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) signed and dated 03/01/2022. There is no documented need for mental health services for R1 in the Physician’s Report. However, the facility did not seek medical attention for R1 regarding the incident on 11/02/2022 and the incident on 10/07/2022.

Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated.

On the allegation: Staff violated resident’s visitation rights. It is alleged that the administrator informed a visitor to the facility that they had the right to deny visitation to family members.

LPA confirmed a credible witness acknowledged that the administrator was informed that R1 and all residents in care at the facility have a right to visitations by their family members and others in general. The credible witness determined that R1 wanted to be visited and participate in outings from the facility with visitors. Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 29-AS-20231127090429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748
VISIT DATE: 09/23/2024
NARRATIVE
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The admission agreement to the facility for R1 signed and dated on 02/24/2022 indicates that the agreement must include the facility policy concerning family visits and communication. The policy must be designed to encourage regular family involvement with the resident. The policy must also provide ample opportunity for family participation in family activities. The documented facility visiting hours for general visitation is 10:00am-3:00pm daily.

Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated.

On the allegation: Facility failed to update responsible party on resident's status. On 11/02/2022, R1 was allegedly found unresponsive on the front deck of the facility. Paramedics arrived and determined R1 had very low blood pressure and irregular heartbeat. R1 was admitted to the hospital, but staff informed the responsible party of R1 that they were just napping on the porch of the facility. Allegedly staff failed to inform the responsible party of R1 about the extent of the elopement of R1 on 09/09/2023 and the medical treatment required.

On 11/02/2022, R1 was sitting outside facility on the front porch area waiting for their responsible party to come and pick them up. When the responsible party for R1 arrived, they found R1 unresponsive. The responsible party had to alert the administrator in the facility to come and observe. Staff informed the responsible party of R1 that they had just had contact with R1, and informed responsible party of R1 that R1 was napping on the porch of the facility. However, when paramedics arrived after responsible party called 911, they determined R1 had very low blood pressure and irregular heartbeat. R1 was admitted to the hospital. Licensee failed to report to Licensing the elopements by R1 10/07/2022 and on 09/09/2023. Additionally, Licensee failed to report to Licensing the falls by R1 on 08/24/2022 and 10/09/2022. On 11/28/2023, Licensing Program Analyst (LPA) conducted an initial complaint investigation visit to the facility above. During this visit, LPA requested and received relevant facility documentation pertinent to the allegation above for record review. LPA received an Unusual Incident/Injury Report (UIR) handwritten by the facility administrator for the fall incident by R1 on 10/09/2022, but this UIR was never submitted nor received by Licensing at the time of the incident.

Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. Exit interview conducted. Copy of report provided to facility.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
11/27/2023 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20231127090429

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:
09/23/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Susan Marsh, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility has physical plant issues
Staff spoke inappropriately to residents
Staff do not provide residents with adequate food service
Staff did not safeguard residents' belongings
Staff mismanaged residents' medications
INVESTIGATION FINDINGS:
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On 9/23/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Administrator Sue Marsh and explained the reason for the visit.

On the allegation: Facility has physical plant issues. It is alleged that the ramp and railings on the front deck of the facility are unsafe. Allegedly the facility did not replace a portion of railing and left an open area with a falling/tripping hazard. It is also alleged that on 03/17/2022, it was learned upon arrival at the facility that R1’s standard wheelchair would not fit through the doorway to their bedroom and the bathroom adjacent to R1’s bedroom had no room for a wheelchair. A smaller junior sized wheelchair was purchased by the responsible party of R1 to use while in the facility.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 29-AS-20231127090429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748
VISIT DATE: 09/23/2024
NARRATIVE
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LPA conducted physical site visits to the facility on 11/28/2023, 02/23/2024, and 09/23/2024 including an annual facility site inspection. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected and observed the front outdoor area of the facility, which consists of cement walkways and grass areas. The facility outdoor front yard area is paved with a walkway up to the front door of the facility. The front yard has a patio with shade and outdoor furniture conducive for outdoor visitation. During all visits by LPA, there were no observed front deck ramp and railing safety hazards which would cause immediate or potential harm to residents in care at the facility.

Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

On the allegation: Staff spoke inappropriately to residents. It is alleged that the administrator of the facility has verbally abused facility staff members causing them to quit employment. It is also alleged that the facility administrator yelled at visitors to the facility in front of residents, which caused emotional distress to residents. Additionally, it is alleged that the facility administrator makes derogatory statements to visitors.

Administrator was reminded by LPA to minimize negative/derogatory statements to staff and/or visitors to the facility. The admission agreement to the facility for R1 signed and dated on 02/24/2022 indicates that the licensee must advise the resident or responsible person of, and provide a copy of, the resident’s personal rights specified by law. The advisement of personal rights and signed copy of personal rights are initialed by R1’s responsible party. According to the allegation, staff did not speak inappropriately to residents, but to visitors and other staff members.

Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

On the allegation: Staff do not provide residents with adequate food service. It is alleged that R1 complained often about the poor quality of the food in the facility. Because of R1’s alleged complaints about the food, R1 was brought food to the facility by visitors on numerous occasions.

On 02/23/2024, the LPA conducted an annual facility site inspection of the facility above. Contd. on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 29-AS-20231127090429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748
VISIT DATE: 09/23/2024
NARRATIVE
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LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The LPA inspected the kitchen/food service area and observed that perishable food items were in good condition, with proper expiration dates precluding the perishable items from expiring. The facility had a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). The freezer and refrigerator were both the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. There was emergency food and water in the garage of the facility and in the extra perishable food storage area which was observed to be in good condition. Kitchen appliances were in operable condition and looked clean/in good repair. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. LPA also visited the facility above for complaint investigation visits on 11/28/2023 and 09/20/2024. During these complaint investigation visits, LPA did not observe any food of poor quality i.e. spoiled/rotten/expired within the facility. Additionally, LPA did not observe any appliances or kitchenware in disrepair that would lead to inadequate food service.

Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

On the allegation: Staff did not safeguard residents' belongings. It is alleged that staff told R1 not to bring personal food items to the facility because staff see Resident #2 (R2) taking R1’s belongings on a consistent basis. Allegedly R1 ordered and paid for 2 large pizzas, but only got one piece before the entire pizza was taken.

On 02/23/2024, the LPA conducted an annual facility site inspection of the facility above. During this annual inspection, LPA interviewed both Staff and residents in care. LPA additionally conducted on-site facility observations on 11/28/2023 and 09/20/2024. During all visits to the facility by LPA and concurrent interviews with Staff and residents, no statement was made by either any Staff or any resident that resident belongings are not safeguarded in the facility. LPA did not physically observe any resident belongings not being safeguarded by Staff in the facility during visits on 11/28/2023, 02/23/2024, or 09/20/2024.

Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 29-AS-20231127090429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748
VISIT DATE: 09/23/2024
NARRATIVE
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On the allegation: Staff mismanaged residents' medications. It is alleged that the facility administrator ordered the responsible party of R1 to order more medications for R1 as R1 was out. The responsible party of R1 provided the date the prescription was to be filled and noted it was too early. The staff eventually found R1’s extra medication in an overflow bag. Allegedly staff at the facility administered medications to R1 that were not prescribed by a physician and withheld medications that were prescribed by a physician. Staff allegedly argued medications for R1 were not needed even though they were prescribed by the primary physician of R1.

On 11/28/2023, LPA conducted a complaint investigation visit to the facility above. During this visit, LPA requested and received relevant facility documentation pertinent to the allegation that Staff mismanaged residents’ medications for record review. LPA received R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) signed and dated 03/01/2022. Under medication management, the Physician’s Report indicates that R1 is able to administer their own medications, but they need a medication box set up for them to take their medications. Facility documentation received by LPA from August 2023 indicated the outdated/not currently prescribed medications for R1. These medications were prescribed previously for R1 by their primary care physician (PCP) but are not on a current physician report and/or are not currently prescribed by R1’s PCP. The facility documented that these medications were taken out of R1’s medication box as of August 2023. The Medication Administration Record (MAR) for R1 from August 2023 onward indicates that the medication alleged by RP that was being administered to R1 by Staff despite not being prescribed by a physician, was discontinued and there is no documented evidence of R1 being prescribed this medication any further. Based on interview by LPA with Staff on 11/28/2023 and 09/20/2024, there is no evidence that the facility administrator ordered the responsible party of R1 to order more medications for R1 as R1 was out. LPA interviews with Staff additionally did not corroborate that staff eventually found R1’s extra medication in an overflow bag.

Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

Exit Interview Conducted. Copy of this report provided to the facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 29-AS-20231127090429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2024
Section Cited
CCR
87468.2(a)(4)
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Addt'l Personal Rights Residents...(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, services that meet individual needs…delivered by staff sufficient in numbers, qualifications, competency…
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Licensee will provide all Staff with a training on Resident Personal Rights and incidents/situations requiring Staff to assist residents with medical attention. Evidence of this training will be provided to LPA by 09/24/2024.
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This requirement is not met based on records review, licensee did not comply with the section cited above when Resident #1 eloped from facility without staff knowledge, and was not provided medical attention by facility which posed an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type B
10/21/2024
Section Cited
CCR
87468.1(a)(11)
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Personal Rights All Residents...(a) Residents in all residential care facilities for the elderly shall have following personal rights: (11) To have visitors…permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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Licensee will provide all Staff with a refresher training on the facility visitiation policy as documented on facility resident admission agreement. Evidence will be provided to LPA by 10/21/2024.
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This requirement is not met based on interviews/records review, licensee did not comply when a visitor to the facility was informed by Staff that they had the right to deny visitation to family members, which posed a potential 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: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 29-AS-20231127090429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/21/2024
Section Cited
CCR
87468.1(a)(8)
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Personal Rights...(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
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Licensee will provide all Staff with Personal Rights training regarding residents in care at the facility. Training will include personal rights training for all deficiencies cited, including the informing of responsible parties when a resident has a change in condition.
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This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with section cited above by failing to report an incident and change of condition to a resident’s responsible party, which posed a potential 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: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
Page: 10 of 10