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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850225
Report Date: 10/30/2024
Date Signed: 10/30/2024 01:20:29 PM

Unsubstantiated


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
09/11/2024 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20240911213422
FACILITY NAME:FAMILY CONNECT MEMORY CARE SOLVANGFACILITY NUMBER:
425850225
ADMINISTRATOR:MAHAKIAN, LAURENFACILITY TYPE:
740
ADDRESS:659 CHALK HILL ROADTELEPHONE:
(310) 383-1877
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY:6CENSUS: 5DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:VirginaTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner.
Staff did not issue proper refund.
INVESTIGATION FINDINGS:
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On 10/30/24 at 9:55 am Licensing Program Analyst (LPA) Melisa Rankin arrived at the above Facility to conduct an final Complaint Investigation Site Visit. LPA met with Administrator Lauren Mahakian and House Manager Virginia Rodriguez and explained the purpose of the visit.

On 9/18/24 LPA Rankin and LPM Burley toured facility, conducted interviews and gathered the following documents from the Family Connect Memory Care (FCMC) facility; progress notes, intake record, LIC 602a Physician’s Report, admission record, email from Family #2 (F2) to administrator, August, and September Medication Administration Records (MAR), current staff schedule.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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-20240911213422
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: FAMILY CONNECT MEMORY CARE SOLVANG
FACILITY NUMBER: 425850225
VISIT DATE: 10/30/2024
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On allegation that Staff did not issue proper refund:
It was alleged R1 was not eligible for a refund for September 2024 rent, despite moving out. On 8/23/24 Family #1 (F1) signed an Admission Agreement for Resident #1 (R1). Per admission agreement it states in the section 17, page 8 “17. Termination of Agreement: You may terminate this Agreement at any time with a 30-day written notice.” R1 went to the hospital on 9/6/24. Further evidence of understanding of this agreement is an email dated 9/6/24 at 8:31 AM from F2. The email states “My (R1’s) family has decided that the best course for (R1) is to grant (R1) request that (R1) be moved to the Texas home of (R1’s family member). This email is the (family last name) 30-day written notice of termination of their agreement with you for my (R1’s) care.” No refund for R1 is required at this time, based on the admission agreement.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On the allegation that Staff did not seek medical attention for resident in a timely manner.
It was alleged that R1 fell out of bed on 8/30/24 and that on 8/31/24 F1 requested R1 be evaluated and was told R1 needed rest and they would monitor R1. After a week R1’s leg was getting worse per F1 and on 9/6/24 they requested the facility call 911. Determination was a Subcapital proximal femur fracture which required surgery.
On 9/17/24 at 8:57 am LPA interviewed F1 and on 9/30/24 at 3:27 pm LPA interviewed F2 regarding allegation. Both stated they visited R1 on 8/31/24 at approximately 11:00 am. F1 stated that facility informed them that R1 had “fell out of bed” the day before (8/30/24). Both informed LPA that R1 could barely talk or eat, “very groggy”. F2 stated during the visit R1 would “Talk a little and fall asleep” and “complained about right leg hurting.” F1 stated facility told them R1 “had trouble sleeping so they gave R1 extra sleeping medication.” F1 stated on 09/03/24 F1 and a friend visited R1 again and R1 was still in pain, not groggy. F1 stated only Tylenol was given but R1 had stronger medications. F1 stated on 09/06/24 they arrived early for a visit and watched as 2 female staff moved R1 to their wheelchair from a recliner. F1 stated R1 was in pain from the transfer, that R1 was loud when moved.
Continued 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20240911213422
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: FAMILY CONNECT MEMORY CARE SOLVANG
FACILITY NUMBER: 425850225
VISIT DATE: 10/30/2024
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During visit F1 stated Hospice Staff #1 (H1) was present and when F1 asked facility to call 911 Staff #1 (S1) said “R1 is on hospice so we don’t call 911 for hospice patients.” H1 signed R1’s hospice release papers and 911 was called by F1. R1 was transported to the hospital, had x-rays and scans done, revealed there was a blood clot developing above right knee and right femoral neck fracture. F1 stated surgery was performed on 09/07/24.

On 9/18/24 during visit LPM and LPA Interviewed with staff and conducted record reviews which confirmed that R1 had fallen on 8/30/24 at approximately 4:00 pm. It was observed in R1’s room that their bed was lowered to what was stated as “the lowest level” and a fall mat was located below it, in support of anyone who is a fall risk.

Documentation provided by facility show that R1 was at Lompoc Comprehensive Care Center (CCC) prior to their transfer to this facility. Progress notes documentation states on 8/21/24 “At shift change during CNA rounding, resident was found on the floor. (R1) was laying on (their) back on the L side of the bed between the bed…Resident was very agitated and refusing care and becoming combative...Routine Ativan and Tylenol given but resident spit medication out...” Following that incident medication notes on 8/21/24 at 11:45 pm, 8/22/24 am, 8/22/24 3:50 am, 8/22/24 5:15am, 8/22/24 6:15 am, show Morphine Sulfate given by mouth every 1 hours as needed for pain. Due to patients’ agitation, multiple Vital Signs being attempted and refused due to agitation. After the fall a “denuded area above the right foot” was treated. On 8/22/24 charted at 8:14 am it states “Called (F1) and made aware of patient’s fall and aggressive behavior.” Also charted Lorazepam was given every 4 hours as needed for restlessness. “Patient appear combative, trying to hit nurse during medication administration.” The CCC progress notes documentation show prior to moving FCMC, patient had a fall, was experiencing and taking medications for pain, agitation, and was being aggressive with CCC staff. Progress notes for CCC show that 8/21/24 a request for “increase lorazepam dose and obtain PRN along with new order for Morphine… resident has been having increased restless and pain…” Additionally notes state family informed them that R1 took morphine at home.
Continued 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 29-AS-20240911213422
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: FAMILY CONNECT MEMORY CARE SOLVANG
FACILITY NUMBER: 425850225
VISIT DATE: 10/30/2024
NARRATIVE
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On 8/23/24 R1 moved to the FCMC. Intake document “Comprehensive Skin Assessment” dated 8/23/24 shows R1 had a Foley catheter, a bruise on their left forearm, two abrasions on their right leg just above ankle, pain in the middle back along spine, pain in right inner thigh below buttocks, pain in right hip. A Physician’s Report for Residential Care Facilities for Elderly was given to the facility dated 8/22/24, noting that R1 was on a pureed diet and had a foley catheter and that R1 has Mild Cognitive Impairment.

On 9/18/24 LPM and LPA interviewed S1, S2, and Licensee. S1 stated a resident that came from CCC “already been through trauma at CCC, was overmedicated…Rolled out of bed.” All three acknowledged R1 had “rolled out of bed” on 8/30/24 at approximately 4:00 pm. S2 stated R1 was lying in bed, “they put the fall mat down, they checked on R1 every 10 minutes, last time they checked on R1 the alarm went off about 2 minutes after the prior check, they found R1 laying down, on top of the floor matt.” S2 stated they assessed R1, there was no pain, no skin tears, or bruises. Put (R1) in the wheelchair because (R1) wanted to be with other residents." "Called Hospice... they told (S2) to check to see if any pain or discoloration." Hospice came the next day. S2 stated "(R1) complained their leg was sore... and asked for Tylenol." Next day "Honey leg feels sore", no bruising, previous co-worker said R1 slept through the night, R1 was able to move their leg. S2 helped R1 during shifts with changing their briefs after the catheter was removed 8/27/24 S2 stated when changing briefs R1 would say "watch out leg was sore." "Would complain of leg pain." R1 was still able to move both legs. S2 stated R1 always complained leg was "sore". Hospice would come and do regular checks ups. R1 was still joining in activities. R1 would "Walk in wheelchair." Participated in bending exercise. R1 would engage.

Interview with S1 they stated R1 had only been at the facility for 2 weeks, fell on 8/30/24. R1 "went to take a nap, girls found (R1) on (R1's) side." “If a resident is on hospice, they call hospice. F1 had R1 on hospice. S1 stated "(R1) was doing good." They didn't think R1 needed 911. (F1) came and said they needed 911 so they called. S1 added R1 was eating good. R1 was participating, tossing the ball, exercising. There was nothing going on that would show R1 was not ok. Hospice came 2 times a week. Per S1 Hospice stayed in contact with F1.

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

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20240911213422
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: FAMILY CONNECT MEMORY CARE SOLVANG
FACILITY NUMBER: 425850225
VISIT DATE: 10/30/2024
NARRATIVE
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During interview with Licensee/Administrator, she stated R1 had a fall mat, the bed was on lower settings to lower risk. She stated hospice was called following the event when R1 “rolled off the bed”. She stated R1 had “numerous falls” while at CCC. She stated F1 came and toured facility on 8/23/24 and wanted R1 moved in the same day. Their RN on staff spoke with CCC nurse, they knew R1 was coming in with a Catheter, but stated they didn’t know why R1 had a catheter. She stated within days R1 was in a good mood, staff RN and H1 met, and they took R1 off morphine and used Tylenol. Per administrator she understood that R1 had been put on a catheter when at home, facility got catheter removed. Per LIC 602a and per F1, R1 ate pureed food. Facility tested “soft chop” to see if R1 could tolerate.

Per administrator F1 showed up approximately 10:30 am on 9/6/24 with the nurse from hospice. According to the administrator F1 said R1 is lethargic, R1’s leg is in pain, I want you to call the ambulance. S1 called administrator and then ambulance.

On 10/4/24 LPA interviewed H1. H1 stated they began attending to R1 when R1 was in their home. F1 had R1 moved from home to CCC. R1 was at CCC for “6 days and had a fall while (they) were there.” When at CCC "F1 did not like that R1 had a fall there and it was taking too long to get medication for pain." On 8/23/24 R1 was transferred to this facility. H1 stated “While at the facility (R1) also had a fall. Facility did call hospice to let them know R1 had a fall. (R1) was sore, but pain was relieved by Tylenol.” H1 stated "R1 was doing exercise and was participating with activities" at the facility. "No signs or symptom of grimacing." There was pain when transferring. On 08/31/24 after R1 fell a nurse came for a visit to assess R1's leg. Per H1, she was told that F1 said "(R1) had company and they had to do the dressing change and then hurry up." For the following days R1 was in pain when they would be transferred. But no pain when sitting. On following Wednesday 09/03/24 H1 went to check, no family there, but did notice transfer painful, no swelling or signs of bruising. Palliative Care Change note from Hospice requested on 9/3/24 to start tramadol 50 mg, 1 table every 6 hours for pain. When H1 gave report to Family #3 (F3) and F1 they asked if R1 had a possible fracture from fall. H1 said it was a possibility. "If they wanted to get x-rays or screening done, they could revoke hospice.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20240911213422
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: FAMILY CONNECT MEMORY CARE SOLVANG
FACILITY NUMBER: 425850225
VISIT DATE: 10/30/2024
NARRATIVE
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H1 said they understood." On 09/06/24 R1 had a visit and they discussed possibility of fracture again, and repeated that they could revoke. F1 decided to revoke hospice and R1 was sent to the hospital. At no time did facility try to refuse care. On 9/3/24 before R1 got off hospice Val did have a PRN for tramadol ordered in case Tylenol was not enough and facility did try to give R1 that, but it made R1 sleepy. R1 did not appear in pain when sitting in a chair.

LPA asked, “After fall at CCC facility did H1 notice anything change for R1 at CCC?” H1 stated - "Hard to tell because at CCC F1 kept requesting more pain mediation and Ativan and more anti-anxiety medication and R1 would fall asleep." H1 noticed an "Increase in anxiety from home to CCC and decrease in anxiety from CCC to this facility." At CCC it was Ativan 1 x every 4 hours. "…because R1 was on so many medications it was hard to tell if R1 was in pain. It was hard to get anything from R1 due to medication.” R1 didn't complain of pain, and occasionally would say "(they) had leg pain, but the Tylenol would relieve that. No tramadol or PRN morphine was given until later the week after the 2nd fall, then with the transfers it was more painful. LPA asked why H1 had the discussion about taking R1 off hospice with F1 and F3, H1 stated it was because of the pain caused from transfers.

LPA asked do you know if the CCC sent R1 out after the fall to be evaluated? H1 stated they do not know if they tried to get R1 evaluated. H1 stated - "A little different situation because (R1) is on hospice, normally (outside of hospice) they would evaluate and send out, (for hospice patients) usually they manage the symptoms, but if the family wants to revoke than they can." Per H1 "CCC was trying to medicate as needed. F1 was insistent on medicating R1.”

On 9/20/24 LPA went to Cottage Hospital in Santa Barabara, CA and met with Reporting Party (RP) to discuss complaint. RP stated they only know what occurred after a discussion with F1. During visit RP pulled up notes for R1 and provided the following notes. On 9/6/24 at 12:20 pm, Emergency Department Provider notes, “final diagnosis Closed fracture of right hip, acute deep vein thrombosis of femoral vein of right lower extremity. Moderate dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety.”
Continued 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20240911213422
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: FAMILY CONNECT MEMORY CARE SOLVANG
FACILITY NUMBER: 425850225
VISIT DATE: 10/30/2024
NARRATIVE
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Stated "very pleasant gentleman, with right thigh and knee pain...... On examination (R1) has swelling through the right medial and distal thigh with tenderness, there is no erythema or warmth or other skin changes besides the swelling. (R1) denies any hip pain." Page 2 of notes again states "(R1) denies pelvic and upper hip pain."

Interviews and records regarding prior CCC stay provided evidence that R1 sustained a fall at CCC, that no follow-up was done after that fall on 8/21/24, that R1 was on Morphine every hour for pain which began on 8/21/24 at 11:45 pm, and was combative and agitated. Intake records show that R1 came into the facility with some pain in the right hip and thigh. Interviews and records provided would indicate that R1 was improving based on reduced agitation, compliance with medication, no combative behavior, the removal of catheter, participation in activities, and the change in food intake. Hospice was with R1 from home to introduction into facility and did not request transfer of patient due to, observing no significate change or pain indication. Facility informed hospice of incident at their facility and complied with hospice requests. Interviews with staff state patient stated they were “sore” and ER record notes state patient denied pelvic or upper hip pain. Based on what the facility knew of R1 for the one (1) week they were there prior to the fall and based on intake and Hospice nurse notes no new indications would have told the facility that the pain is not R1’s normal baseline.

Based on the above information the allegation, Staff did not seek medical attention for a resident in a timely manner, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Copy of report printed and given to Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7