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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850214
Report Date: 09/30/2024
Date Signed: 09/30/2024 01:52:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/05/2024 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20240405155913
FACILITY NAME:VILLA-CARE HOME IFACILITY NUMBER:
425850214
ADMINISTRATOR:RUST, JESSICAFACILITY TYPE:
740
ADDRESS:938 WEST BUNNY AVENUETELEPHONE:
(805) 928-5654
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 5DATE:
09/30/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jessica Rust - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not prevent a resident from falling and sustaining fractures while in care.

Staff are sleeping during shifts.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) M. Rankin conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Jessica Rust and explained the reason for the visit.

On 04/05/2024, the Department received a complaint regarding staff neglect and lack of supervision of R1 resulting in R1 sustaining a fracture from a fall while in care. The complaint also alleged staff were sleeping during their shifts. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Heidy Bendana.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
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 7
Control Number 29-AS-20240405155913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA-CARE HOME I
FACILITY NUMBER: 425850214
VISIT DATE: 09/30/2024
NARRATIVE
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On 04/10/2024, from 9:35am to 11:00am, Licensing Program Analysts (LPAs) Rachael De Leon and Melisa Rankin conducted the 10-day complaint visit to the facility. LPAs De Leon and Rankin met with the Administrator and explained the purpose of the visit. The LPAs requested records pertinent to the investigation. LPA De Leon requested video footage for the dates of 03/29/2024 through 03/30/2024 for the camera located in the common area hallway and living room. The Administrator was informed the complaint was assigned to the Community Care Licensing Division (CCLD) Investigation Branch (IB) and that the investigator would return at a later date to complete the investigation.

On 04/23/2024, from approximately 12:05pm to 1:17pm, the Department’s Investigators Bendana and Miles conducted interviews with the Licensee, Staff #3 (S3), and the Administrator; on 06/05/2024, at approximately 12:36pm, Investigator Bendana conducted an interview with R1’s resident representative; on 06/19/2024, at approximately 11:24am, Investigators Bendana and Miles attempted to interview R1, who was unable to be interviewed due to their dementia; on 08/22/2024, from approximately 12:28pm to 12:54pm, Investigator Bendana interviewed R1’s Primary Care Physician (PCP), and Witness #1 (W1). Staff #1 (S1) and Staff #2 (S2) were unable to be interviewed due to moving out of the country.
In addition, the investigator reviewed Marian Regional Medical Center records, Wilshire Home Health records, RING camera video footage, photos of sensor and alert system of R1’s bedroom, and other facility file documents related to the investigation.

According to the facility file documents reviewed R1 was admitted to the facility on 02/17/2020. The Preplacement Appraisal Information, dated 02/17/2020, listed R1 needed to use a cane or four-wheel walker with seats and brakes.

Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20240405155913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA-CARE HOME I
FACILITY NUMBER: 425850214
VISIT DATE: 09/30/2024
NARRATIVE
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R1’s gait was slow with right leg externally rotated. R1 was diagnosed with dementia and showed signs of confusion/disorientation, sundowning behavior and can follow directions. The most recent Physician’s Report, dated 07/03/2023, listed R1’s primary diagnosis as anxiety disorder, Parkinson’s disease, and hypothyroidism. The secondary diagnosis listed atherosclerotic heart disease of native coronary artery without angina pectoris, restlessness, agitation, and hallucinations, and dementia. R1 had visual impairment, was confused/disoriented with inappropriate behavior, and needed assistance with Activities of Daily Living (ADLs) which included assistance with toileting. It was documented that R1 could transfer independently to and from bed but also indicated R1 was non-ambulatory. R1 had previously sustained a fall at the facility in April 2022, which resulted in a hip fracture. The Appraisal/Needs and Services Plan dated 02/01/2024 documents R1 had a recent stroke and now ambulates and communicates slower. The Plan also documents R1 as having more signs of confusion, forgetfulness, slow getting around but uses walker or wheelchair, and indicates staff assist with mobility.

On 03/07/2024, R1 presented to the Marian Regional Medical Center Emergency Department with the chief complaint of unresponsiveness. The records documented R1 had a known history of acute ischemic stroke, dementia, Parkinson’s, hyperlipidemia, hypothyroidism, iron deficiency, chronic constipation. The Emergency Medical Services (EMS) reported R1 resided at the Villa Care Home, was last seen normal at approximately 11:15am, eating. R1 was then seen slumped over on the couch, staff lowered R1 to the ground and called EMS. EMS noted a right-sided facial droop, low blood pressure and administered IV fluids R1 was admitted for further evaluation and discharged on 03/08/2024 with discharge instructions for fall prevention and ongoing physical and occupational therapy. The hospital Occupational Therapy assessment noted R1 was dependent on toileting and unable to complete toilet transfers due to weakness and symptoms of light headedness.

Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20240405155913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA-CARE HOME I
FACILITY NUMBER: 425850214
VISIT DATE: 09/30/2024
NARRATIVE
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The discharge diagnosis listed fall with possible unwitnessed brief syncope (fainting), and states Patient should have very close standby assist. No records show that R1’s appraisal/needs and services plan was updated after this change in condition to align with hospital records showing R1 needed additional supervision and assistance.

The review of the Unusual Incident/Injury Report submitted by the facility for R1 listed the date of incident as 03/29/2024. The report documents at approximately 1:30am, S1 and S2 heard a loud noise in R1’s room. S1 and S2 found R1 on the floor with an excessive amount of blood coming from R1’s nose. S1 and S2 called 911 immediately and R1 was transported to the hospital. R1 was discharged with a broken nose and UTI. Actions taken or planned were to make sure R1 had motion alarms set in R1’s room and encourage water intake and for R1 to take R1’s prescribed medications. The report also indicated that R1’s resident representative was notified of the incident by the hospital.

According to the Marian Regional Medical Center records, R1 arrived at the Emergency Room on 03/29/2024 at 2:48am, with a chief complaint of fall/nosebleed. The fall was noted to be an unwitnessed fall. The paramedics stated R1 was found lying on the ground. Per facility staff, R1 was acting to R1’s baseline. R1 stated R1 believed they fell coming back from the bathroom because their feet slipped out from underneath them. R1 stated they did not fully remember the event. R1 was found bleeding from the nose and a small hematoma to R1’s forehead. X-rays were taken and results showed left frontal scalp swelling without underlying skull fracture or acute intracranial findings, comminuted nasal bone fracture with soft tissue gas and minimal deviated anterior nasal septum. R1 was negative for acute cervical spine findings. R1 likely has nasal bone fracture without evidence of significant deformity or septal hematoma. R1 complains of tenderness to the knee. The final diagnosis for R1 were closed head injury, nasal bone fracture, epistaxis (nosebleed), pituitary adenoma, and UTI (urinary tract infection).
Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20240405155913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA-CARE HOME I
FACILITY NUMBER: 425850214
VISIT DATE: 09/30/2024
NARRATIVE
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The information obtained from the interviews, incident reports, and medical records indicated R1 sustained an unwitnessed fall on 03/29/2024. During the interviews, the Licensee and the Administrator provided inconsistent statements. The Administrator reported there had “never” been any falls at the facility, then reported R1 had sustained a fall where R1 “broke” their hip. The Administrator stated R1 was a fall risk and had an unsteady gait. The Licensee reported R1 was a fall risk and had fallen during the night. The Licensee explained S1 and S2 found R1 on the floor laying on R1’s stomach. The Licensee revealed R1 had a motion sensor alarm located perpendicular to R1’s bed, on the floor. The Licensee assumed the motion sensor alarm was turned on. Facility staff gave inconsistent statements of how often resident checks are conducted. Per S3, resident checks are conducted every four hours. The Licensee stated the checks are conducted frequently, they should be every hour or every couple of hours. The Licensee and the Administrator reported two (2) staff worked the night shift 7:00pm to 7:00am; however, the facility personnel report dated 02/02/2024 only listed S2 working the night shift. Consequently, the RING camera located near the facility’s front door facing the living room did not capture activity or movement from 7:00pm on 03/28/2024 to 1:57am on 3/29/2024. Per the RING camera footage, the EMS and firefighters arrived at the facility at 2:20am and were taken down the hallway leading to R1’s room. R1’s resident representative was told R1 fell out of R1’s bed and that the sensor alarm went off after R1 fell. The facility knew R1 was a fall risk and needed assistance with ADLs including toileting.

Based on the evidence obtained, the Department determined that it is more likely than not that the caregivers were asleep and did not conduct checks on residents thus neglecting and lacking supervision.

Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20240405155913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA-CARE HOME I
FACILITY NUMBER: 425850214
VISIT DATE: 09/30/2024
NARRATIVE
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The facility staff neglect and lack of supervision resulted in R1 sustaining a fractured nose while in care; therefore, both the allegations “Staff failed to supervise Resident #1 (R1) resulting in R1 sustaining fractures from a fall while in care” and “Staff are sleeping during shifts” 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 LIC9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20240405155913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VILLA-CARE HOME I
FACILITY NUMBER: 425850214
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2024
Section Cited
HSC
1569.312
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§1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and records review, the
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Licensee will submit a plan how you will ensure appropriate care and supervision to meet the needs of residents. Submit to CCL by 10/1/24.
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licensee did not comply with the section cited above when due to a lack of supervision by staff, R1 sustained a fall resulting in a fractured nose, which posed an immediate health and safety risk to residents in care.
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Type A
10/14/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents…shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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Licensee will submit a plan, including a current LIC500 Personnel Report, showing how you will ensure adequate staffing for all shifts to meet the needs of residents. Submit to CCL by 10/1/24
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Based on interviews and records review, the licensee did not comply with the section cited above when staff were sleeping and not conducting regular checks, R1 sustained a fall resulting in a
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fractured nose, which posed an immediate health and safety risk to residents in care.
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: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7