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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800734
Report Date: 04/23/2021
Date Signed: 04/23/2021 03:25:20 PM

Document Has Been Signed on 04/23/2021 03:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HILLCREST ROYALEFACILITY NUMBER:
565800734
ADMINISTRATOR:INGA JAKOBOVICHFACILITY TYPE:
740
ADDRESS:190 EAST HILLCREST DRIVETELEPHONE:
(805) 371-0035
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 145CENSUS: 72DATE:
04/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Inga Jakobovich and Marian RubensteinTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith initiated a Case Management-Incident visit to conclude an investigation initiated during a previous Case Management visit conducted on 4/1/2021. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Marian Rubenstein. The LPA also discussed the findings with Administrator Inga Jakobovich.

On 04/01/2021, the facility submitted an Unusual Incident Report, noting that on 3/16/2021, redness was observed near Resident #1's (R1) coccyx. R1 was taken to urgent care and home health was initiated. Per the report, the wound was staged as a Stage 2, possibly a Stage 3 pressure injury. A wound specialist assessed the wound and daily nursing visits began 3/18/2021. The wound was reassessed on 3/30/2021 and it was identified as a Stage 4 pressure injury. R1 was transported to the hospital on 3/30/2021. The Administrator stated that they left a message for the On-Duty Worker regarding this incident on approximately 3/19/2021.

During the 4/1/2021 visit, the LPA completed a tour, interviewed Ms. Jakobovich, and requested documents. Records review and interviews revealed that on 3/19/2021, a wound specialist observed R1’s coccyx and noted the wound as a Stage 3 pressure injury. The facility initiated wound care, and the facility fulfilled their obligation to treat the wound as required, along with repositioning R1 every two hours. On 3/25/2021, an assessment was conducted on R1, and the pressure injury on the coccyx was noted as unstageable. Subsequent visits on 3/28/2021, 3/29/2021, and 3/30/2021 documented the pressure injury as unstageable. On 3/30/2021, R1 was transported to the hospital and is currently recovering at a skilled nursing facility.

Based on the information obtained, there is sufficient evidence to confirm that the facility retained R1 in the facility with a prohibited health condition, as R1’s wound was noted as a Stage 3 pressure injury, which eventually became unstageable. In addition, the facility did not submit an incident report for the 3/16/2021 urgent care visit. The following deficiencies will be cited (refer to LIC 809-D). Exit interview conducted. A copy of this report, along with appeal rights, was emailed for signature.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2021 03:25 PM - It Cannot Be Edited


Created By: Ashley Smith On 04/23/2021 at 03:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HILLCREST ROYALE
FACILITY NUMBER: 565800734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/26/2021
Section Cited
CCR
87615(a)(1)

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87615(a)(1) Prohibited Health Conditions. Persons who require health services for or have a health condition ... shall not be admitted or retained in a residential care facility for the elderly: Stage 3 or 4 pressure injuries.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
Review Regulation 87615 and submit a Statement of Understanding, detailing how the facility will maintain compliance. Submit statement to CCLD by 4/26/2021.
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Based on interview and records review, the licensee did not comply with the section cited above, as they retained R1 in the facility with a prohibited health condition, which poses an immediate health and safety risk to residents in care.
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Type B
04/28/2021
Section Cited
CCR87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
Review Regulation 87211 and submit a Statement of Understanding, detailing how the facility will maintain compliance. Submit statement to CCLD by 4/28/2021.
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Based on interview and records review, the licensee did not comply with the section cited above, as the licensee did not submit a report when R1 went to the ER on 3/16/2021, which poses 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.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2021


LIC809 (FAS) - (06/04)
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