567609722-12-3-2024-29-AS-ECOZ-DBLQ7D-20241203105459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609722
Report Date: 12/03/2024
Date Signed: 12/03/2024 10:55:42 AM

Document Has Been Signed on 12/03/2024 10:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GRANNYS HOME		FACILITY NUMBER:	567609722
ADMINISTRATOR/ DIRECTOR:	HERNANDEZ, VICTOR		FACILITY TYPE:	740
ADDRESS:	1831 BERNADETTE ST		TELEPHONE:	(805) 278-2273
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 6		CENSUS: 6	DATE:	12/03/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Victor Hernandez		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

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	Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent case management visit to deliver findings for the questionable death investigation initiated on 09/05/2024 case management visit. LPA met with Administrator Victor Hernandez and Assistant Administrator Celesty Hernandez and explained the reason for the visit. On 08/30/2024, the Woodland Hills North Adult & Senior Care Regional Office received a death report which stated Resident #1 (R1) was hospitalized on 08/17/2024, diagnosed with a urinary tract infection (UTI), and passed away on 08/30/2024 while at the hospital. The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Christine Ferris. On 09/05/2024, from 2:30pm to 4:30pm, Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. LPA Cortez met with Administrator Victor Hernandez and assistant Administrator Celesty Hernandez and explained the reason for the visit. The Administrator had to leave during the visit and designated the assistant Administrator to review and sign the report. The reason for the visit was to follow up on a self-reported death report received on 08/30/2024. The report pertained to the death of Resident #1 (R1). Per the information received, the circumstances surrounding the death of R1 on 08/30/2024 may be questionable and needed to be investigated. R1 was sent to the hospital 08/16/2024 and passed away on 08/30/2024 due to UTI/sepsis at the hospital. During the visit, the LPA conducted an interview with the Administrator and assistant Administrator, conducted a brief tour of the facility and obtained copies of pertinent documents. The incident was referred to Community Care Licensing Investigations Branch (IB) and assigned to investigator Christine Ferris. The LPA determined further investigation was required prior to issuing findings. Report will continue on LIC809-C, 2nd page.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: GRANNYS HOME	FACILITY NUMBER: 567609722
	VISIT DATE: 12/03/2024

NARRATIVE

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On 10/09/2024, from approximately 12:30pm to 3:00pm, Investigator Ferris conducted interviews with the Administrator, assistant Administrator, caregiver, residents, and resident representatives; and on 10/22/2024, at approximately 1:00pm, with Viva Home Health Licensed Vocational Nurse (LVN). In addition, St. John’s Regional Medical Center medical records, Viva Home Health medical records, County of Ventura Certificate of Death, and facility file documents related to R1 and were obtained and reviewed.

A review of R1’s facility file noted R1 was admitted to the facility on 03/1/02024. The physician report dated 03/08/2024 documented R1 had mild cognitive impairment (MCI), required assistance with all activities of daily living including bathing, dressing, grooming, feeding and toileting. R1 was listed as not able to transfer to and from bed and considered to be non-ambulatory. R1’s resident appraisal dated 03/03/2024, listed R1 as bedridden with frequent UTIs (Urinary Tract Infections). The resident file also contained a Dr. order dated 05/21/2024, for a C-PAP machine due to R1’s diagnosis of obstructive sleep apnea. In addition, R1’s facility file review included St. John’s Regional Medical Center medical records which revealed R1 was seen on 04/29/2024, 12/14/2023, and 11/18/2023 for visits where R1 was diagnosed with UTIs.

According to the Viva Home Health medical records, R1 was seen by home health approximately twice per week from 04/1/2024 to 08/13/2024. The home health documents listed R1’s diagnosis as Parkinson’s disease, type 2 diabetes, hyponatremia, bipolar disorder, muscle weakness, and hypertension. Per the Viva Home Health records, a visit on 08/13/2024 had no notation of illness or concern. Per the Viva Home Health Licensed Vocational Nurse, they saw nothing concerning and stated they found the facility staff to be “attentive” and the residents well cared for.

According to the assistant administrator, on 08/16/2024, at approximately 2:00pm, they tried to wake R1 up for a “snack” due to R1’s diabetes, but R1’s response was reminiscent of when R1 had a prior UTI as R1 was not as responsive as usual. The assistant administrator called 911 to have R1 transported to the hospital. R1 later telephoned the hospital and was told R1 had another UTI. The assistant administrator added R1 has a history of UTIs, so they were aware of what to look for. The assistant Administrator explained R1 could verbalize if they had any pain or discomfort, but R1 did not do so on that day. Per the facility staff interviewed, R1 showed no signs of illness until 911 was called and R1 was transferred to the hospital.

Report will continue on LIC809-C, 3rd page.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: GRANNYS HOME	FACILITY NUMBER: 567609722
	VISIT DATE: 12/03/2024

NARRATIVE

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According to the St. John’s Regional Medical Center medical records, on 08/16/2024, R1 was admitted to St. John’s Regional Medical Center with altered mental status and sepsis, suspected due to a UTI. R1’s past medical history listed paroxysmal atrial flutter/atrial fibrillation, hypertension, hyperlipidemia, type 2 diabetes mellitus, and bipolar disorder.

The records revealed R1 had multiple comorbidities as listed in the discharge diagnoses such as acute hypoxemic respiratory failure, metabolic encephalopathy, and atrial fibrillation with rapid ventricular response. In addition, the records noted there were no specific symptoms related to genitourinary tract, though the patient was being treated for urosepsis. There was no concern for neglect/lack of care notated in the records. R1 was transitioned to comfort care on 08/27/2024. Comfort care measures were continued, and hospice was consulted. R1 passed away on 08/30/2024.

The County of Ventura Certificate of Death listed the immediate cause of death as acute hypoxemic respiratory failure. The conditions leading to the cause of death were listed as pneumonia organism unknown, metabolic encephalopathy, urinary tract infection Escherichia coli bacterium. Other significant causes contributing but not resulting in the underlying cause were atrial fibrillation, myotonic dystrophy type 2, Parkinson’s Disease, and hypertension.

The Department’s investigation did not provide sufficient evidence to substantiate neglect/lack of care. Therefore, the allegation “Neglect/Lack of Care: Staff neglected to provide an adequate level of care resulting in Resident #1 (R1) dying from sepsis while hospitalized” is deemed Unsubstantiated at this time.

Exit interview, copy of report given.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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