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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802430
Report Date: 11/19/2024
Date Signed: 11/20/2024 09:51:42 AM

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
07/18/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230718163058
FACILITY NAME:SELECT SENIOR LIVING IFACILITY NUMBER:
565802430
ADMINISTRATOR:HULL, DYLANFACILITY TYPE:
740
ADDRESS:1363 FEATHER AVETELEPHONE:
(805) 852-5059
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Kim AndersonTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Resident fell sustaining injuries due to staff neglect.
Staff did not seek medical attention for resident.
Staff are overmedicating resident.
Staff are not meeting resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced investigation visit for the
allegations listed above. The LPA arrived at the facility and was greeted by staff, and the LPA informed them of the visit. The staff contacted the Licensee Dylan Dylan Hull on the phone to inform them of the visit. Kim Anderson Licensed Vocational Nurse (LVN) arrived and the LPA explained the reason for the visit.

On 07/24/2023, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial investigation visit for the allegations listed above. The LPA arrived at the facility and met with Administrator Dylan Hull and Kim Anderson and explained the reason for the visit. At 11:30 a.m., the LPA interviewed the administrator, and staff and at 12:00 p.m., conducted record review pertinent to the investigation. At this time LPA Urena found that further investigation is needed.

Continues on LIC 9099C ...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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 4
Control Number 29-AS-20230718163058
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: SELECT SENIOR LIVING I
FACILITY NUMBER: 565802430
VISIT DATE: 11/19/2024
NARRATIVE
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Pg 2.
Resident fell sustaining injuries due to staff neglect.
On the allegation that the resident sustained a fall due to staff neglect, it is the concern of the Reporting Party (RP) that R1 has fallen a few times since R1 moved into the facility on 05/06/2023. RP stated that on 5/22/2023, R1 was taken to the ER due to a fall and brought back to the facility, only to fall again the next day. To investigate the allegation LPA Urena conducted interviews and record review. Record review of the Unusual /Injury/Incident Reports (LIC 624) submitted to the Regional Office (RO) indicated that R1 had an unwitnessed fall on 05/29/2023 at approximately 6:40 p.m. Staff found R1 on the floor trying to fix their shoe and noticed that R1 sustained two small skin tears to the top of their hand. Furthermore, on the second page of the LIC 624 indicates that Home Health was notified to provide wound care. Staff interviews revealed that they found R1 on the floor and after doing an assessment they noticed a skin tear to the top of the right hand. The staff contacted the licensee and the licensee contacted R1’s physician and home health were contacted to provide wound care to R1’s hand.Staff stated that during the day R1 was closely monitored to assist and tried to prevent falls. Record review of the Home Health “Visitor Care Notes”, revealed that Home Health was providing wound care for R1. On 07/24/2023, LPA Urena interviewed the Licensee. Per the licensee, R1 would get up at night and try to ambulate to the bathroom on their own, and this is the time when R1 sustained the falls. Night supervision is one (1) staff to six (6) residents. Motion detectors devices are placed in each room to detect residents getting up from there bed, consequently alerting the night staff. The LPA observed the motion detector monitor located in the living room and a voice is heard saying the name of the room where the movement was detected. Staff attended to the alert coming from the residents’ bedrooms.

Although R1 fell and sustained a laceration to the top of the right hand due to a fall, the staff provided first aid and notified the licensee. The licensee in turn contacted the physician’s and order home health. Based on the information obtained through interviews and record review, there is insufficient evidence to find that staff were neglectful. Therefore, the allegation is deemed Unsubstantiated at this time.

Continues on LIC 9099C... pg.3
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20230718163058
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: SELECT SENIOR LIVING I
FACILITY NUMBER: 565802430
VISIT DATE: 11/19/2024
NARRATIVE
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Pg 3
Staff did not seek medical attention for resident.
On the allegation that staff did not seek medical attention for R1, the RP stated that they visited R1 on 6/28/2023 and there were no signs that R1 was sick, however, when RP visited on 07/02/2023, R1 was unresponsive, had shallow breathing, and looked bad. RP stated that the staff didn’t know what to do and called the facility nurse. RP stated that the nurse came in and said, “What do you want me to do?” RP stated that they couldn’t believe that staff couldn’t tell there was something wrong with R1. RP stated that staff checked R1’s oxygen levels, and it was at 90%. RP stated that RP had to tell the staff to call 911. R1 was taken to the hospital, and R1 was diagnosed as having pneumonia. The staff interviews revealed that R1 appeared to be normal on the days preceding the incident, however, on 07/02/2023 R1 was lethargic during the day, however there were no signs of distress, no high temperature, skin looked normal. R1’s representative was visiting with R1 on 07/02/2023, and the representative noticed that R1 did not look well. Staff checked the R1’s oxygen level, which was measured at 90% (normal level is 95%). Staff contacted the facility’s LVN and told the LVN that R1’s representative was requesting to call 911 for R1. Staff called 911, and R1 was transported to the hospital for evaluation. R1 was diagnosed as having pneumonia.
Based on the interviews, observation, record review, there is insufficient evidence to prove that staff failed to seek medical attention for resident. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff are over medicating resident.
It is alleged that R1 was being over medicated by staff, however the RP does not know what was being given to R1 to cause R1 to appear sedated, and lethargic. To investigate the allegation, on 07/24/2023 and 11/19/2024, LPA Urena conducted record review of the Centrally Stored Medication and Destruction Record (LIC 622), and interviewed the administrator, the LVN, staff, and RP. The record review indicated that all the medications were prescribed by R1’s physician. One of the medications prescribed to R1, indicate that the side effects may be drowsiness, dizziness, nausea and headache. The staff interviews revealed that they assisted R1 with the medication per the instructions on the LIC 622. The facility LVN stated that R1 was prescribed Temazepam for agitation. The interview with the RP revealed that all medications being given to R1 were prescribed by R1's physician.
Based on the information obtained through interviews and record review; staff was assisting R1 with medications as prescribed by R1’s physician. Therefore, the allegation is deemed Unsubstantiated at this time.



SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20230718163058
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: SELECT SENIOR LIVING I
FACILITY NUMBER: 565802430
VISIT DATE: 11/19/2024
NARRATIVE
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Pg. 4

Staff are not meeting resident's needs.
On the allegation that staff are not meeting the resident’s needs, it is the concern of the RP that although a home health care nurse was taking care of R1’s skin tear, RP had to take care of the wounds on the days home health nurse was not present, because the staff weren’t taking care of it properly. To investigate the allegation the LPA conducted interviews and record review. The interviews revealed that R1 sustained a skin tear on top of their hand, and Home Health was providing wound care. Record review revealed that home health was providing wound care every three days starting on 05/29/2023 through 06/29/2023. Facility staff understand that they are not skilled professional, consequently they cannot provide wound care. Staff kept wound dry by preventing it from getting wet during showers.

Based on the interviews and record review, R1 was receiving wound care by a skilled professional as indicated by the physician’s orders. Therefore, the allegation is deemed Unsubstantiated at this time.

No citations were issued. Exit interview was conducted. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4