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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850097
Report Date: 10/05/2022
Date Signed: 10/05/2022 11:49:26 AM

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
08/30/2022 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20220830110458
FACILITY NAME:CAMARILLO HAVENFACILITY NUMBER:
565850097
ADMINISTRATOR:CATABAY,ERIKA GRACEFACILITY TYPE:
740
ADDRESS:154 CAMINO CASTENADATELEPHONE:
(805) 512-0102
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 6DATE:
10/05/2022
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Grace CatabayTIME COMPLETED:
11:48 AM
ALLEGATION(S):
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Resident sustained unstageable pressure injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegation listed above. LPA arrived at the facility at 10:14 AM and initially met with facility staff. Licensees Grace and Teddy Catabay arrived at 10:35AM. Entrance interview conducted.

During today’s visit, LPA toured the facility at 10:39AM with Licensee Grace Catabay. No immediate health and safety hazards were identified. During an initial complaint visit on 08/31/2022, LPA toured the facility with Licensee at 12:19PM, interviewed licensees at 10:36AM and 11:06AM, interviewed staff at 12:23PM, and LPA gathered copies of pertinent documents. LPA reviewed documents related to Resident #1 (R1) throughout the course of the investigation. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
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 2
Control Number 29-AS-20220830110458
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: CAMARILLO HAVEN
FACILITY NUMBER: 565850097
VISIT DATE: 10/05/2022
NARRATIVE
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Record review revealed that R1 had been hospitalized four (4) different times between 07/07/2022 and 08/26/2022. Hospital records reviewed for the initial 07/07/2022 hospitalization did not indicate a pressure injury at the time of hospitalization or discharge from the hospital. Incident report sent to the Regional Office indicates on 08/02/2022, facility staff noticed a pressure injury on R1’s sacral area. Interviews revealed that as soon as staff noticed the pressure injury, Licensee was notified, and R1’s conservator and primary care physician (PCP) were notified. When R1’s PCP was unable to schedule a visit to observe and care for the wound timely, the Licensee sent R1 to the hospital. R1 returned from the hospital with orders for Home Health to provide pressure injury care at the facility. Home Health began to treat R1’s wound beginning on 08/13/2022, but record review revealed the wound was not staged at that time, nor was it indicated as unstageable. Wound care was conducted every other day until 08/17/2022, when facility staff again sent R1 to the hospital. Hospital records reviewed make no mention of the wound, it’s care or staging at that time. Home Health again visited R1 at the facility beginning on 08/22/2022, when every other day wound care visits resumed. R1 was hospitalized on 08/26/2022 and had yet to be discharged at the time of LPA’s initial complaint visit. On 08/29/2022, a wound consult was conducted at the hospital, where R1 had remained since their 08/26/2022 hospitalization. At the time of the wound consult, it was noted R1’s sacral wound is unstageable and measured 2cm x 2cm larger than home health indicated during their last facility visit on 08/24/2022. Wound consult notes also revealed additional wounds on both of R1’s heels that had not been previously identified during wound care prior to R1’s hospitalization. Home Health records reviewed indicate the sacral wound was getting larger in size during the time period 08/13/2022 – 08/26/2022, while Home Health was providing wound care. Additionally, hospital records reviewed for the first three (3) hospitalizations, did not indicate there was a pressure injury, and therefore did not indicate size or staging. As thus, it is unclear whether R1 sustained the pressure injury while hospitalized or while in the facility. Also, since staging was not completed during the initial Home Health consult or subsequent wound care, there is no way to ascertain whether the wound became unstageable during the course of Home Health care, at the facility, or during a hospitalization. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “Resident sustained unstageable pressure injury while in care” is deemed UNSUBSTANTIATED at this time.

No deficiencies cited. Exit interview was conducted with Licensee. Report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
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