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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850370
Report Date: 06/20/2024
Date Signed: 06/21/2024 07:31:34 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
01/12/2024 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20240112155611
FACILITY NAME:COLONY OF THOUSAND OAKS AT SIDLEE WEST INCFACILITY NUMBER:
565850370
ADMINISTRATOR:AGGARWAL, RASHITAFACILITY TYPE:
740
ADDRESS:171 WEST SIDLEE STREETTELEPHONE:
(805) 496-4541
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Rashita AggarwalTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident sustained a pressure injury while in care.
Staff did not seek timely medical care for resident in care.
Resident sustained unexplained head injury while in care.
Resident in care was severely dehydrated while in care.
Staff medicated resident with an unauthorized medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Urena met with and explained the reason for the visit.

On 01/12/2024, the Department received a complaint alleging neglect, lack of care and supervision regarding Resident #1 (R1). The complaint alleged the facility, Colony of Thousand Oaks at Sidlee West Inc. neglected a pressure injury noted on R1, failed to seek timely medical attention, R1 sustained an unexplained head injury while in care, and noted R1 was severely dehydrated. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Johnny Canto.

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

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
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-20240112155611
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: COLONY OF THOUSAND OAKS AT SIDLEE WEST INC
FACILITY NUMBER: 565850370
VISIT DATE: 06/20/2024
NARRATIVE
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Pg. 2.
On 01/16/2024, from 1:35pm to 2:55pm, Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced, initial 10-day complaint visit to the facility. LPA Campos met with Administrator Connie Roush and explained the reason for the visit. During the visit, the LPA conducted a facility tour at 1:35pm for any immediate health and safety hazards and none were observed, reviewed resident documents at 1:55pm, and obtained pertinent documents. The LPA determined that further investigation was needed and advised Administrator Connie Roush that the complaint was referred to the Department's Investigation Branch (IB) for further investigation.

Investigator Canto and Investigator Jose Santana conducted interviews on 01/23/2024, from approximately 10:00am to 11:30am, with R1, the administrator, staff, and Resident #2 (R2). On 02/09/2024, at approximately 4:15pm, investigator Canto conducted an interview with R1’s resident representative; and on 02/21/2024, at approximately 3:15pm, with R1’s home health nurse. In addition, the investigator reviewed Los Robles Regional Medical Center medical records and facility file documents related to R1.

According to R1’s physician’s report, dated 08/16/2023, the primary diagnosis is listed as dementia, anxiety, and chronic back pain, requires assistance with medications, with a secondary diagnosis of osteoporosis, and GERD Gastroesophageal reflux disease. R1 has no contagious diseases, has a history of skin breakdown, bowel impairment, and bladder impairment disoriented, has sundowning behavior, and can follow instructions and communicate needs. The resident appraisal report, dated 08/28/2023, noted R1 has no dietary limitations, can ambulate with a walker, requires a lot of redirections and prompting, can sometimes be forgetful, has a history of shortness of breath, loves to do puzzles, and loves to draw. R1 can walk without physical assistance.

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

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20240112155611
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: COLONY OF THOUSAND OAKS AT SIDLEE WEST INC
FACILITY NUMBER: 565850370
VISIT DATE: 06/20/2024
NARRATIVE
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Pg. 3.
The Los Robles Regional Medical Center records revealed that on 01/10/2024, at approximately 8:21am, R1 was admitted to the hospital via ambulance. The chief complaint was listed as an unwitnessed fall. Patient with dementia, a history of agitation, multiple psychiatric medications, and hypertension, presenting after an unwitnessed fall from their facility. The patient has bruising and hematoma on head, was complaining of lower back pain. Patient appears to be at their neurological baseline, able to state name, but unable to state the date of birth or location. Stable to follow some simple commands. Patient has some swelling on the shoulder. X-rays taken ruled out any acute fractures. It was noted that R1 was recently diagnosed COVID-positive and being treated. R1 was discharged back to the facility on 01/12/2024.

On the allegation “Neglect Lack of Care & Supervision – Resident sustained a pressure injury while in care”. On 01/10/2024, R1 sustained an unwitnessed fall while residing at the facility. R1 was subsequently admitted to Los Robles Regional Medical Center. Interviews were conducted with R1, the facility administrator, the facility staff, R1’s resident representative and R1’s home health nurse. R1’s resident representative was made aware of the fall by the facility, has never been informed of any pressure injury to R1 while residing at the facility, and believes the facility took appropriate measures when they found R1 on the ground in R1’s room. R1’s resident representative had no concerns as to the quality-of-care R1 receives at the facility. The medical records were reviewed and noted R1’s skin was intact, normal in color, with no rash, and warm and dry. R1’s home health nurse stated R1 had a pressure injury to their heel which was healing appropriately. The Department found no evidence that R1 was admitted to Los Robles Medical Regional Center with a pressure injury. Based on the medical records and interviews conducted, the Department concluded that there was insufficient evidence to substantiate the allegation. Therefore, the allegation “Neglect Lack of Care & Supervision – Resident sustained a pressure injury while in care” is deemed Unsubstantiated at this time.
Continues on LIC 9099C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240112155611
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: COLONY OF THOUSAND OAKS AT SIDLEE WEST INC
FACILITY NUMBER: 565850370
VISIT DATE: 06/20/2024
NARRATIVE
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Pg.4.
On the allegation “Neglect Lack of Care & Supervision – The facility failed to provide timely medical attention for resident while in care”. On 01/10/2024, R1 sustained an unwitnessed fall while residing at the facility. Interviews were conducted with R1, the facility administrator, the facility staff, and R1’s home health nurse. The medical records were requested and reviewed. The facility staff conducted round checks at approximately 6:00am on 01/10/2024 and noted R1 was still in bed, upon completion of their second-round checks at 7:30am, the facility staff discovered R1 on the ground in their bedroom. The facility staff assisted R1 to the couch and assessed R1. The facility staff contacted the facility administrator and were instructed to contact 911 for transfer. Medical records noted that at approximately 7:55am the ambulance arrived at the facility and transferred R1 to Los Robles Regional Medical Center. The Department found no evidence that the facility failed to seek timely medical attention for R1. Based on the medical records and interviews conducted, the Department concluded that there was insufficient evidence to substantiate the allegation. Therefore, the allegation “Neglect Lack of Care & Supervision – The facility failed to provide timely medical attention to resident while in care” is deemed Unsubstantiated at this time.

On the allegation “Neglect Lack of Care & Supervision – Resident sustained an unexplained head injury while in care”. On 01/10/2024, R1 sustained an unwitnessed fall while residing at the facility. Interviews were conducted with R1, the facility administrator, the facility staff, and R1’s home health nurse. Medical records were requested and reviewed. The facility staff conducted round checks at approximately 6:00am on 01/10/2024 and noted R1 was still in bed, upon completion of their second-round checks at 7:30am, the facility staff discovered R1 on the ground in R1’s bedroom. The facility staff assisted R1 to the couch, assessed R1, and noted a discoloration to R1’s temporal/head area. The facility staff photographed and documented their findings. The facility staff contacted the facility administrator and were instructed to contact 911 for transfer. Medical records noted that at approximately 7:55am the ambulance arrived at the facility and transferred R1 to Los Robles Regional Medical Center. While R1 did sustain an unwitnessed fall at the facility which resulted in a head injury, the Department found no evidence that the facility neglected the care of R1. Therefore, the allegation “Neglect Lack of Care & Supervision – Resident sustained an unexplained head injury while in care” is deemed Unsubstantiated at this time.
Continues on LIC 9099C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20240112155611
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: COLONY OF THOUSAND OAKS AT SIDLEE WEST INC
FACILITY NUMBER: 565850370
VISIT DATE: 06/20/2024
NARRATIVE
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Pg. 5.
On the allegation “Neglect Lack of Care & Supervision – Resident was noted to be severely dehydrated while in care”. On 01/10/2024, R1 sustained an unwitnessed fall while residing at the facility. Interviews were conducted with R1, the facility administrator, the facility staff, and R1’s home health nurse. Medical records were requested and reviewed. Upon discovering R1 on the floor of their bedroom, the facility staff contacted 911. R1 was transferred to Los Robles Regional Medical Center. Medical records noted that upon admission, at 8:27am, R1’s sodium level was 134 (Baseline 136-145 mmol/L). R1’s potassium level was noted at 4.8 (baseline 3.6-5.1 mmol/L). R1 was given fluids but was not noted as having severe dehydration. The Department found no evidence that the facility neglected the care of R1 leading to severe dehydration. Therefore, the allegation “Neglect Lack of Care & Supervision – Resident was noted to be severely dehydrated while in care” is deemed Unsubstantiated at this time.

On the allegation of “Staff medicated resident with an unauthorized medication -Resident has been over-medicated with antipsychotic medications without proper authority”. On 01/16/2024, LPA Campos obtained a list of medications created by Los Robles Hospital and was collected as part of the pertinent records to be reviewed for the allegation above. The list of medications was printed on 01/12/2024. On 06/20/2024, LPA Urena conducted a review and audit of the Centrally Stored Medication and Destruction Record Form (LIC 622) and obtained additional records pertaining to the allegation. Review of the LIC 622 revealed that the medications listed on the LIC 622 are prescribed by R1's attending physician. Therefore, the allegation that “Resident has been over-medicated with antipsychotic medications without proper authority”-is deemed Unsubstantiated at this time.



Exit interview conducted, copy of this report issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5