565801597-4-14-2022-29-AS-DPEA-CDX2XV-20220428174744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801597
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:19:14 PM

Unsubstantiated

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
11/16/2021 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20211116133659

FACILITY NAME:	A LOVING HEART SENIOR CARE		FACILITY NUMBER:	565801597
ADMINISTRATOR:	DIORENA ROCK/ MICHEAL V.		FACILITY TYPE:	740
ADDRESS:	28 WALES STREET		TELEPHONE:	(805) 230-3818
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Diorena Rock		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility did not allow residents responsible person to select their own Physician
Facility is not following their visiting policy

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 11/22/2021 by LPA’s M. Guzman Chavez and A. Smith. On today’s visit, LPA Guzman Chavez met with Administrator, Diorena Rock. Entrance interview conducted.

During the initial visit on 11/22/2021, LPA’s Guzman Chavez and Smith conducted and interview with the Administrator at 11:43 a.m., began interviews with five residents at 2:25 p.m., and interviewed a family member of a resident at 1:38 p.m. The LPA’s also reviewed files and obtained copies of pertinent documents. LPA Guzman Chavez also interviewed other resident family members on 4/07/2022 between 2:27 p.m. and 4:16 p.m.

...Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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 7

Control Number 29-AS-20211116133659

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: A LOVING HEART SENIOR CARE	FACILITY NUMBER: 565801597
	VISIT DATE: 04/14/2022

NARRATIVE

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...Conitnued from LIC 9099...
It was alleged that facility did not allow residents responsible person to select their own physician. It was reported that facility did not allow Resident #1’s (R1’s) family to speak to any doctors and ignored R1’s HMO group plan that was used when R1 was admitted. Interviews with the Administrator revealed that they ‘introduced’ R1’s family to their current Primary Care Physician (PCP), and the family ‘agreed’ to switch doctors. Additionally, R1’s first appointment with the new PCP was on 6/16/2021, and since then became R1’s PCP. Furthermore, interviews with random resident family members revealed that facility never spoke to them about any other doctor as they had their own up on admitting their family member to the facility. However, interviews with other random resident family members revealed that facility recommended a doctor when arriving at the facility, but they ‘never felt obligated’ to choose a specific PCP for their family members. Although facility recommends a PCP upon admittance, it is not a requirement for the family members to switch PCP. Based on interviews, the Department does not have sufficient evidence to support the allegation of “facility did not allow residents responsible person to select their own Physician”. Therefore, the allegation is deemed Unsubstantiated at this time.

Also alleged was facility is not following their visiting policy. It was reported that facility only allowed R1’s family members to visit on Sunday’s. Review of records revealed that facility had implemented a visitation plan which stated, ‘visitors to be scheduled in advance’, ‘be subject to staff availability’, and ‘a limitation to the number of visitors to enter at any one time’. On 08/27/2021, the Department sent out a Provider Information Notice (PIN) Summary 21-17.2-ASC to all licensed facilities with best practices for visitation which stated, ‘limit the number of visitors on the facility premises at any one time to avoid having large groups congregate’. Per Administrator interviews, they try to create a schedule so there aren’t overlapping visits or too many families visiting at the same time. Administrator stated to suggesting Sunday’s from 11am – 1pm as the set date and time for R1’s family to visit R1. Interviews conducted revealed that R1’s family members were asked not to come unannounced and it was better to schedule in advance. Interviews with random family members revealed that earlier in the pandemic, they had to call ahead to make sure it was okay to come visit. Although family members were asked to call ahead and schedule, there were no concerns in doing so afterwards as a family member stated, ‘we usually send a text message giving them a heads up that we are on our way’. Based on interviews and record review, the Department does not have sufficient evidence to support the allegation of “facility is not following their visiting policy”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. A copy of report provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 7

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
11/16/2021 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20211116133659

FACILITY NAME:	A LOVING HEART SENIOR CARE		FACILITY NUMBER:	565801597
ADMINISTRATOR:	DIORENA ROCK/ MICHEAL V.		FACILITY TYPE:	740
ADDRESS:	28 WALES STREET		TELEPHONE:	(805) 230-3818
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS:	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Diorena Rock		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility is not allowing residents responsible person access to resident records
Facility increased resident rate without a change in residents’ level of care
Facility did not meet residents’ needs
Facility retained resident with a prohibited health condition

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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 7

Control Number 29-AS-20211116133659

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: A LOVING HEART SENIOR CARE	FACILITY NUMBER: 565801597
	VISIT DATE: 04/14/2022

NARRATIVE

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COntinued from LIC 9099A...

It was alleged that facility is not allowing residents responsible person access to residents records. On 11/14/2021, Resident #1’s (R1’s) Power of Attorney (POA) had verbally asked facility to obtain any of R1’s records. But they were told that they were entitled to none and could not see any files. Interviews with the Administrator revealed that if someone puts in a request for records, they prepare the documents, and the receiving party has to ‘sign off’ on the documents that were received. Per record review, on 11/18/2021, R1’s POA submitted a written request to the Administrator of A Loving Heart Senior Care requesting ‘copies of all resident files’. Yet, the Administrator denied ever being asked about reviewing or obtaining records. Additionally, Administrator claimed, ‘when people ask, I give it to them’ and added that R1’s responsible party requested records on 11/21/2021, which she then informed them that they were ‘in the process of updating the records’. Although documents were finally released, they were not released to the requesting party within the time allotted by regulations. Therefore, based on interviews and documents obtained and reviewed, the allegation “facility is not allowing residents responsible person access to residents records” is deemed Substantiated at this time.

It was also alleged that facility increased resident rate without a change in residents’ level of care. Facility sent R1’s POA an email on 8/19/2021 that explained how the level of care of R1 had changed since being admitted to the facility. Record review of HH nurses notes from 6/18/2021 revealed R1 was initially assessed as ‘unable to transfer self and is unable to bear weight or pivot when transferred by another person’. Also, assessment noted R1 to be ‘totally dependent in toileting’. Interviews with the Administrator revealed that R1’s care needs ‘drastically changed’ and they had to pay staff more. Additionally, per the Administrator, after R1’s hospitalization, R1 could no longer bear weight, legs were swollen, needed to go to the bathroom more often, and needed regular transfer assistance. Although an email was provided to R1’s family, the Administrator admitted to not providing an updated appraisal or physician’s report as they stated they ‘could not keep up with all the paperwork’. Additionally, the Administrator gave R1’s POA notice regarding fee increase but did not discuss the change in care plan with both R1’s POA and PCP. Based on all information gathered during the course of the investigation, the above allegation, “facility increased resident rate without a change in residents’ level of care” is deemed Substantiated at this time.

...Continued from LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 29-AS-20211116133659

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: A LOVING HEART SENIOR CARE	FACILITY NUMBER: 565801597
	VISIT DATE: 04/14/2022

NARRATIVE

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Continued from LIC 9099C...

It was further alleged that facility retained resident with a prohibited health condition and facility did not meet residents’ needs. It was reported that on 11/21/2021, R1 was evaluated and found to have a pressure injury on their sacrum. Information obtained revealed R1 was admitted to this facility on 06/14/2021 as non-ambulatory, wheelchair bound and had been previously assessed to have a history of skin condition or breakdown. Record review of Physician’s Orders revealed R1’s PCP referred R1 to Infinite Home Health (HH) on 6/24/2021 for wound care as R1 had a skin tear on their right leg. HH nurse was going to the facility every weekday to perform wound care and assess R1’s level of pain. During these visits, HH nurse was also conducting full body checks. On 10/11/2021, HH nurse notes stated R1 had four (4) open wounds and hx issues to buttocks. Additionally, HH nurse continuously educated facility staff on ‘repositioning and protection of bony prominences’ and staff ‘verbalized understanding of education provided’. Interviews revealed R1 was taken out of the facility for a doctor’s appointment on 11/12/2021. Administrator stated that when R1’s family took R1 out of the facility for two (2) hours with the vascular doctor, they obtained a bruise. Consequently, R1 was assessed on 11/15/2021 by a skilled nurse with deep tissue injury / unstageable wound to sacrum. Although both the facility and HH were continuously providing wound care to R1, record review revealed the Administrator was made aware of the pressure injury on R1’s sacrum on 11/15/2021 and both acknowledged and signed off on the nurse’s notes. Furthermore, the Administrator did not have R1 transferred to a hospital or contact R1’s PCP to obtain further instructions regarding the need for higher level of care. Facility retained R1 in the facility for another six (6) days with the unstageable wound. Based on the information and documentation obtained and reviewed, the allegations of “facility retained resident with a prohibited health condition” and “facility did not meet residents’ needs” are deemed Substantiated at this time.

The following deficiencies are observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. An immediate $500 civil penalty is being assessed today. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Exit interview conducted. Citation issued. Appeal Rights discussed. A copy of report provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 29-AS-20211116133659

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: A LOVING HEART SENIOR CARE	FACILITY NUMBER: 565801597
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/14/2022 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615(a)(1)Prohibited Health Conditions Persons who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure sores (dermal ulcers). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to the following: 1.) Do an in-house training with staff on Regulation 87615 and submit proof to CCL by 4/29/2022. 2.) Submit a Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87615 and submit to CCL by 4/29/2022.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the licensee did not comply with the section cited above as R1 developed an unstageable pressure injury and was retained at the facility without being under hospice care, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type A 04/14/2022 Section Cited CCR 87668.2(a)(19)	1 2 3 4 5 6 7	87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning… changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to submit a Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87466 and submit to CCL by 4/29/2022.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as the facility did not properly report or document R1’s change in health condition with both R1’s PCP and POA, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 29-AS-20211116133659

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: A LOVING HEART SENIOR CARE	FACILITY NUMBER: 565801597
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 04/29/2022 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	87468.2(a)(19) 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 in privately... (19) To have prompt access to review all of their… records shall be provided within two (2) business days… This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to submit a Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87468.1 and submit to CCL by 4/29/2022.
	8 9 10 11 12 13 14	Based on interviews, and record review, the licensee did not comply with the section cited above as they failed to produce requested records to POA within the time allotted by regulation of two (2) business days, which poses a potential risk to the personal rights of residents in care.	8 9 10 11 12 13 14
Request Denied Type B 04/29/2022 Section Cited CCR 87463(c)	1 2 3 4 5 6 7	87463(c) Reappraisals. (c)The licensee shall arrange a meeting with the resident, the resident’s representative and a representative of the resident’s HH when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	POC: The Administrator has agreed to submit a Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87463 and submit to CCL by 4/29/2022.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as the licensee did not inform R1’s POA about the change in R1’s condition, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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