<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802441
Report Date: 10/30/2024
Date Signed: 10/30/2024 02:29:49 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
06/29/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230629151129
FACILITY NAME:LOVELY COMMUNITY HEALTHCAREFACILITY NUMBER:
565802441
ADMINISTRATOR:TOUME, CILVAFACILITY TYPE:
740
ADDRESS:52 W NORMAN AVENUETELEPHONE:
(805) 852-8770
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Cilva ToumeTIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is not providing adequate care and supervision to resident.
Resident sustained an injury from a fall at the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to deliver the findings for the allegations listed above. The LPA was greeted by staff and contacted the Administrator via telephone. The Administrator Cilva Toume arrived thereafter, and the LPA explained the reason for the visit.

On 07/05/2023, Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for an initial 10-day complaint investigation. The LPA met with Staff at 10:35 a.m., Administrator Cilva Toume arrived shortly thereafter, and LPA explained the reason for the visit. During today's visit, the LPA toured the facility, interviewed staff at 9:45 a.m.,10:00 a.m., and 10:15 a.m., interviewed residents at 10:30 a.m. and 10:35 a.m. Attempted interviews with 3rd parties at 11:13 a.m. and 11:29 a.m. and collected pertinent documents.

Continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
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 5
Control Number 29-AS-20230629151129
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: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441
VISIT DATE: 10/30/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Pg.2
Staff is not providing adequate care and supervision to resident.
On the allegation that Staff is not providing adequate care and supervision to resident; it is the concern of the Reporting Party (RP) that the resident (R1) was not being monitored by staff and allowed R1 to self-harm by allowing R1 to self injure their fingers.

To investigate the allegation LPA Elsie Campos interviewed staff, and administrator on 07/05/2023. The staff’s (S1) interview revealed that R1 came back from the hospital with bite marks to their fingers, however, the bites were covered with bandages. Furthermore, S1 stated that they were attending to R1’s biting injuries by changing the bandages and keeping the wounds clean two times a day, every day. S1 stated that they called the home health nurse on June 20th, 2023, to inform them that they had noticed that R1 had continued to self-bite their fingers. Staff’s (S2) interview revealed that after R1 came back from hospital on 06/18/2023, R1 came back with signs of biting on R1’s hands, “they didn’t look bad, so we covered R1’s palms for prevention, but then R1 started biting their fingers. We informed R1’s responsible party, and the nurse about the concern when R1 came back from the hospital. We (staff) were monitoring R1 throughout the day and night to prevent any further self-harm.

The Administrator’s interview revealed that R1 returned from the hospital after the 06/15/2023 fall with home health services. The Administrator added that staff reported right away to the Administrator when they noticed that R1 started biting their hand and fingers; furthermore, the administrator contacted R1’s responsible party and the home health nurse to inform them of the hand/finger biting. On 10/22/2024, LPA Urena spoke with the RP and interviewed them on the phone. The RP stated that when they were changing the dressings on the right hand of R1, they noticed additional self-inflicted injuries to R1’s right hand fingers and hand. LPA Urena was unable to communicate with the attending home health nurse. Home Health was being provided per hospital discharge instructions for the injury to the forehead due to the fall at the facility, and an abrasion to the hand which happened at the hospital.
Continues on LIC 9099C... pg.3
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
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 5
Control Number 29-AS-20230629151129
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: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441
VISIT DATE: 10/30/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Pg. 3

On 10/28/2024, LPA Urena received and reviewed medical records for R1 from the attending hospital. The medical records indicate that R1 was admitted on 06/29/2023 with Diagnosis: open wounds to right hand, necrotic (dead cells/skin tissue) in appearance to the finger. Areas of necrosis in right distal 5th digit. R1 underwent debridement of right hand and right small finger amputation due to gangrene and eschar.

Based on the information obtained through interviews and record review, staff was not providing adequate care and supervision to resident; consequently, staff did not notice the change of condition of R1 and allowed R1 to further self-harm an open wound. Therefore, the allegation is deemed Substantiated at this time.

Resident sustained an injury from a fall at the facility.
On the allegation that Resident sustained an injury from a fall at the facility; it is the concern of the Reporting Party (RP) that the resident (R1) was not being monitored by staff and R1 sustained a fall that required hospitalization. To investigate the allegation LPA Campos interviewed staff, and administrator on 07/05/2023. The interviews revealed that the first time R1 fell on 04/03/2023, it was an unwitnessed fall. Staff was conducting the morning rounds, at approximately 5:30 a.m. at which time, R1 was still in bed. The second time staff did their morning rounds at approximately 6:30 a.m. R1 was found lying on the floor, staff noticed a skin tear, staff applied first aid, contacted the administrator and the administrator contacted the responsible party for R1. R1 was taken to the hospital for evaluation. The second fall happened on 06/15/2023, while staff assisted R1 to use the commode, when R1 got up from the commode, R1 lost their balance, staff were unable to hold them up, and R1 fell to the floor. R1 was taken to the hospital for evaluation. Per the administrator’s interview, R1 came back to the facility with stitches on their forehead. Staff and administrator stated that the R1 walked slowly with the aid of a walker and sometimes needed assistance with transferring. Staff stated that they monitored and assisted R1 throughout the day.

Continues on LIC 9099C...Pg. 4
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
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 5
Control Number 29-AS-20230629151129
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: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441
VISIT DATE: 10/30/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Pg. 4
On 10/22/2024, at approximately 4:00 p.m., LPA Urena interviewed R1’s representative (POA). The POA stated that R1 suffers from dementia and is non-ambulatory. R1 was at risk of falling because R1 was frail, and because R1 still insisted on getting up on their own to use the commode. R1 was admitted to the facility on 01/13/2023. On 04/03/2023, R1 had their first fall, but was not witnessed by staff. Staff found R1 laying on the floor and was observed to have a skin tear on the face, consequently POA was informed of the fall and took R1 to the hospital to be checked out. POA stated that they spoke to the Administrator about getting someone to provide 1-to-1 caregiver for R1, because R1 could get up from the bed on their own if they felt that they needed to use the commode, but needed assistance and was at risking of falling. POA stated that the administrator and the POA worked out a deal for each to pay half of the cost for 1-to-1 caregiver. The 1-to-1 caregiver provided care for about five (5) to six (6) weeks, then the caregiver left. On 06/15/2023, R1 had a second fall, sustained a cut to the face and R1 complained that they could not stand up. R1 was taken to the hospital to be evaluated.

Record review of the physician’s report dated 12/06/2022 indicate that R1 had diagnosis of Cognitive Disorder and was non-ambulatory. Page 2)-Under section PHYSICAL HEALTH STATUS for motor impairment: It indicated that R1 had no motor impairments. Page 4) under section CAPACITY FOR SELF-CARE: “Observation recommended for safety”. Review of the R1’s Resident Appraisal (LIC603A) states under SERVICES NEEDED: Needs special observation/night supervision (due to confusion, forgetfulness, wondering) YES. LPA Urena reviewed discharge papers from the hospital dated 06/18/2023. The discharge papers indicated a diagnosis of ‘weakness of bilateral legs, fall, and glabellar laceration (area between the eyebrows and above the nose).

Based on the information gathered through interviews and record review, the information revealed that it was agreed between the administrator and the POA that R1 required a 1-to-1 caregiver due to R1’s risk of falling. Furthermore, the Physician’s report stated that “observation was recommended for safety”; and although it does not specify what type of safety, it clearly stated that “observation was recommended for safety”. R1 sustained a fall that required a two (2) day hospitalization. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).
Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
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 5
Control Number 29-AS-20230629151129
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: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
87705(a)(4)
1
2
3
4
5
6
7
Care of Persons with Dementia (a)This section applies to licensees who accept or retain residents diagnosed by a
physician to have dementia… (4) There is an adequate number of direct care staff to support each resident’s.
physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is
not met as evidenced by:
1
2
3
4
5
6
7
POC: Administrator agreed to do the following: Review the regulation and obtain training for all staff (Administrator and staff) on care of persons with dementia.
8
9
10
11
12
13
14
Based on observation and record review, the licensee did not comply with the section cited above as R1 was not provided with adequate care and supervision, which caused R1 to sustain falls and injuries.
8
9
10
11
12
13
14
Type B
11/08/2024
Section Cited
CCR
87463(a)(3)(b)
1
2
3
4
5
6
7
Reappraisals-(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes
and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical,
mental... Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the
health... (b)The licensee shall immediately bring any such changes to the attention of the resident's physician and his
family or responsible person. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
POC: Administrator agreed to do the following: Review regulation and obtain training for all staff (Administrator and staff) on residents’ change of conditions and reporting requirements.
8
9
10
11
12
13
14
Based on observation and record review, the licensee did not comply with the section cited above as R1 was not provided with adequate care and supervision allowing R1 to cause an injury that required amputation.
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: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5